Trends in Mortality and Costs of Pediatric Extracorporeal Life Support.

BACKGROUND: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations. METHODS: We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008-2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs. RESULTS: Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalizations increased 329%, from 11 to 46 cases per 100 000 pediatric hospitalizations, from 2008 to 2015 (P < .001). Overall mortality decreased from 50.3% to 34.6% (P < .001). Adjusted hospital costs increased significantly ($214 046 ± 11 822 to 324 841 ± 25 621; P = .002) during the study period despite a stable overall hospital LOS (46 ± 6 to 44 ± 4 days; P = .94). CONCLUSIONS: Use of ECLS in pediatric patients has increased with substantially improved ECLS survival rates. Hospital costs have increased significantly despite a stable LOS in this group. Dissemination of this costly yet life-saving technology warrants ongoing analysis of use trends to identify areas for quality improvement.

Low-flow assessment of current ECMO/ECCO2R rotary blood pumps and the potential effect on hemocompatibility.

BACKGROUND: Extracorporeal carbon dioxide removal (ECCO2R) uses an extracorporeal circuit to directly remove carbon dioxide from the blood either in lieu of mechanical ventilation or in combination with it. While the potential benefits of the technology are leading to increasing use, there are very real risks associated with it. Several studies demonstrated major bleeding and clotting complications, often associated with hemolysis and poorer outcomes in patients receiving ECCO2R. A better understanding of the risks originating specifically from the rotary blood pump component of the circuit is urgently needed. METHODS: High-resolution computational fluid dynamics was used to calculate the hemodynamics and hemocompatibility of three current rotary blood pumps for various pump flow rates. RESULTS: The hydraulic efficiency dramatically decreases to 5-10% if operating at blood flow rates below 1 L/min, the pump internal flow recirculation rate increases 6-12-fold in these flow ranges, and adverse effects are increased due to multiple exposures to high shear stress. The deleterious consequences include a steep increase in hemolysis and destruction of platelets. CONCLUSIONS: The role of blood pumps in contributing to adverse effects at the lower blood flow rates used during ECCO2R is shown here to be significant. Current rotary blood pumps should be used with caution if operated at blood flow rates below 2 L/min, because of significant and high recirculation, shear stress, and hemolysis. There is a clear and urgent need to design dedicated blood pumps which are optimized for blood flow rates in the range of 0.5-1.5 L/min.

What Should We Learn From Early Hemodialysis Allocation About How We Should Be Using ECMO?

Early hemodialysis allocation deliberations should inform our current considerations of what constitutes reasonable uses of extracorporeal membrane oxygenation. Deliberative democracy can be used as a strategy to gather a plurality of views, consider criteria, and guide policy making.

Organization and Application of ECLS Therapy-A Nationwide Survey in German Cardiosurgical Departments.

BACKGROUND: In context of the multidisciplinary German scientific guideline "Use of extracorporeal circulation (extracorporeal life support [ECLS]/extracorporeal membrane oxygenation) for cardiac and circulatory failure," a nationwide survey should depict the status of organization and application of ECLS therapy in Germany. METHODS: Between June and October 2017, a standardized questionnaire consisting of 30 items related to ECLS therapy was sent to all German cardiosurgical departments, and all returned results were analyzed and evaluated. RESULTS: The return rate amounted to 92.9% (78 out of 84 departments). In the participating departments, ECLS therapy is subject to different responsibilities, and exhibits divergent processes and various ways for specialization of the involved personnel. This also concerns local application standards, such as cannulation strategies, anticoagulation management, left ventricular unloading, antiwatershed treatment, and weaning from circulatory support. CONCLUSION: This nationwide survey underlines the necessity of a multidisciplinary guideline concerning ECLS therapy.

Echocardiographic Assessment of Biventricular Function in 249 Patients During the Peri-Extracorporeal Membrane Oxygenation Period.

OBJECTIVES: At a quaternary care center that regularly performs and cares for patients undergoing extracorporeal membrane oxygenation (ECMO), a database of all adult patients since 2009 was assembled with echocardiographic parameters of left (LV) and right (RV) ventricular function. From the database, 175 venoarterial (VA) and 74 venovenous (VV) ECMO patients were analyzed to compare the decannulation echocardiographic assessments of biventricular function before, during, and after ECMO in survivors and nonsurvivors. DESIGN: Retrospective chart review-based study. SETTING: A single quaternary care center. PARTICIPANTS: All adult patients who received ECMO from 2009 to 2017 with both survival data and echographic studies were included in this retrospective study. INTERVENTIONS: When indicated, transthoracic and transesophageal echocardiograms were performed for ECMO patients. The results of these echocardiograms were reviewed retrospectively, and differences between survivors and nonsurvivors were examined. MEASUREMENTS AND MAIN RESULTS: A retrospective chart review of before, during cannulation, and after decannulation echocardiographic assessments of biventricular function was performed. On average, VA ECMO survivors had better post-decannulation LV function than did nonsurvivors by a full clinical grade-mild impairment versus moderate impairment (p < 0.001). RV function comparison was similar-mild impairment in survivors versus moderate impairment in nonsurvivors (p = 0.007). LV and RV function before and during ECMO in survivors was not different from that of nonsurvivors. The change in biventricular function from before to after cannulation and during cannulation to post-cannulation was approximately a full clinical grade better in survivors than nonsurvivors (p < 0.01 in all cases). In VV ECMO patients, post-decannulation RV function was significantly worse in nonsurvivors (moderate dysfunction vs borderline normal function) (p = 0.013). CONCLUSIONS: Retrospective chart review of 249 patients suggests that echocardiographic assessment of biventricular function before ECMO cannulation is not prognostic in VA or VV ECMO patients. Post-decannulation assessment of biventricular function may aid in triaging more "at risk" patients because nonsurvivors have significantly worse biventricular function after decannulation. The failure to improve biventricular function from the before to after ECMO phases and the during to after ECMO phases is concerning for a poor prognosis.

Extracorporeal membrane oxygenation in Korea - Trends and impact of hospital volume on outcome: Analysis of national insurance data 2009-2014.

PURPOSE: ECMO use has increased lately. However, differences between adult ECMO and non-ECMO patients admitted to the ICU remain unstudied. In terms of volume-outcome relationship, the impact of ECMO volume on survival has not been validated in a real world cohort. MATERIALS AND METHODS: Retrospective analysis of data from the Korean Health Insurance Review and Assessment Service over 5 years, between August 1, 2009 and July 31, 2014. The ECMO group comprised patients who received ≥1 ECMO run. Data on patient demographics, ICU and hospital length of stay, cost, treatments, and in-hospital mortality were collected. Usage trends were analyzed by 5 one-year periods. RESULTS: Among 1, 265, 508 ICU patients, 6078 underwent ECMO during the study period. The number of ECMO patients rose by 2.5 times, and ECMO hospitals from 50 to 86 between periods 1 and 5. Compared to non-ECMO patients, the ECMO group was younger (59 years vs. 64 years, p < .0001) with more comorbidities. Healthcare expenditure and in-hospital mortality in the ECMO group were higher (US $23,600 vs. $5100; 63.4% vs. 12.6%; p < .0001). Using multivariable analysis, age ≥ 50 years, CRRT, and annual hospital ECMO volume < 20 negatively impacted survival to discharge. CONCLUSION: The prevalence of ECMO among ICU patients was 0.5%. The expenditure and in-hospital mortality of the ECMO group were four and five times higher than non-ECMO group respectively. An annual hospital ECMO volume ≥ 20 may improve survival to hospital discharge.

Technical Advances in the Field of ECMO.

Although the fundamentals of extracorporeal membrane oxygenation (ECMO) have not changed in 3 decades, the technical elements continue to improve and have evolved from an assemblage of individual components to more integrated systems with added features, enhanced safety, and improved maneuverability. The introduction of polymethylpentene (PMP) fiber technology has expanded the development of artificial membranes that have low resistance, are more biocompatible, and can be used for extended durations. Extracorporeal carbon dioxide removal techniques continue to be enhanced as stand alone technology and modified renal dialysis systems are introduced. Research continues in the development of compact and wearable artificial lungs that are intended to support patients for prolonged periods (eg, patients awaiting lung transplantation). The use of high-fidelity simulation training has become a standard and important method for reinforcing technical skills, refining troubleshooting sequences, and enhancing team interactions. Modifications to mannequins and ECMO systems coupled with clinical and physiologic scenarios will help achieve greater realism and enhance learning. ECMO technology continues to improve, with adaptability and versatility being essential attributes.

National trends, predictors of use, and in-hospital outcomes in mechanical circulatory support for cardiogenic shock.

AIMS: Despite rising rates of cardiogenic shock (CS), data on trends and in-hospital outcomes of short-term non-durable mechanical circulatory support (MCS) are limited. Thus, we aimed to identify recent national trends in MCS utilisation in the USA, patient-level predictors of MCS use, and in-hospital outcomes in CS inclusive of extracorporeal membrane oxygenation (ECMO). METHODS AND RESULTS: Hospitalisations of US adults with a discharge diagnosis of CS, from January 2004 to December 2014, in the National Inpatient Sample were included. Rates of MCS were stratified by device type and clinical presentation. Outcomes included in-hospital mortality, hospitalisation costs, and number of procedures. A total of 183,516 hospitalisations with CS (47,636 [25.9%] involving MCS) were included. MCS recipients were younger, less frequently female, received more procedures, had higher costs, and more frequently presented with MI (MCS vs. non-MCS: 71.6% vs. 42.9%; p<0.0001). Growth in CS hospitalisations (214.4%) outpaced annual MCS use (160.0%), with relative declines in intra-aortic balloon pump use starting in 2008. Right heart catheterisation rates for both groups remained low (MCS vs. non-MCS: 5.9% vs. 3.3%; p<0.0001). In-hospital mortality declined but remained high in both groups (MCS vs. non-MCS [2014]: 32.7% vs. 41.5%; p<0.0001). CONCLUSIONS: In-hospital mortality for CS has declined but remains high. Rates of CS have outpaced MCS utilisation which remains uncommon in non-MI hospitalisations with shock. MCS is associated with utilisation of other procedures during hospitalisation.

New Innovations in Circulatory Support With Ventricular Assist Device and Extracorporeal Membrane Oxygenation Therapy.

The past decade has seen an exponential increase in the application and development of durable long-term as well as nondurable short-term mechanical circulatory support for cardiogenic shock and acute or chronic heart failure. Support has evolved from bridge-to-transplant to destination therapy, bridge to rescue, bridge to decision making, and bridge to a bridge. Notable trends include device miniaturization, minimally invasive and/or percutaneous insertion, and efforts to superimpose pulsatility on continuous flow. We can certainly anticipate that innovation will accelerate in the months and years to come. However, despite-or perhaps because of-the enhanced equipment now available, mechanical circulatory support is an expensive, complex, resource-intensive modality. It requires considerable expertise that should preferably be centralized to highly specialized centers. Formidable challenges remain: systemic inflammatory response syndromes and vasoplegia after device insertion; postoperative sepsis; optimal anticoagulation regimens to prevent device-induced thrombosis and cerebral thromboembolism; wound site, intracranial, and gastrointestinal bleeding; multisystem injury and failure; patient dissatisfaction (even when providers consider the procedure a "success"); and ethical decision making in conditions of futility.

Microcirculatory assessment of patients under VA-ECMO.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival. METHODS: Twenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48-72 h after initiation of VA-ECMO (T2), 5-6 days after (T3), 9-10 days after (T4), and within 24 h of VA-ECMO removal. RESULTS: Of the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772-1.0). CONCLUSION: PVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock.

Increased trend in extracorporeal membrane oxygenation use by adults in the United States since 2007.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been increasingly studied as a life support modality, but it is unclear if its use has changed over time. Recent publication shows no significant trend in use of ECMO over time; however, this report does not include more recent data. We performed trend analysis to determine if and when the use of ECMO changed in the past decade. RESULTS: We identified hospitalizations (2000-2011) in the Nationwide Inpatient Sample during which ECMO was recorded. We used a segmented linear regression model to determine trend and to identify a temporal change point when rate of ECMO use increased. ECMO use gradually grew until 2007, at which time there was a dramatic increase in the rate (p = 0.0003). There was no difference in mortality after 2007 (p = 0.3374), but there was longer length of stay (p = 0.0001) and smaller percentage of women (p = 0.005). CONCLUSIONS: There has been a marked increase in ECMO use since 2007. As ECMO use becomes more common, further study regarding indications, cost-effectiveness, and outcomes is warranted to guide optimal use.

An insight into short- and long-term mechanical circulatory support systems.

Cardiogenic shock due to acute myocardial infarction, postcardiotomy syndrome following cardiac surgery, or manifestation of heart failure remains a clinical challenge with high mortality rates, despite ongoing advances in surgical techniques, widespread use of primary percutaneous interventions, and medical treatment. Clinicians have, therefore, turned to mechanical means of circulatory support. At present, a broad range of devices are available, which may be extracorporeal, implantable, or percutaneous; temporary or long term. Although counter pulsation provided by intra-aortic balloon pump (IABP) and comprehensive mechanical support for both the systemic and the pulmonary circulation through extracorporeal membrane oxygenation (ECMO) remain a major tool of acute care in patients with cardiogenic shock, both before and after surgical or percutaneous intervention, the development of devices such as the Impella or the Tandemheart allows less invasive forms of temporary support. On the other hand, concerning mid-, or long-term support, left ventricular assist devices have evolved from a last resort life-saving therapy to a well-established viable alternative for thousands of heart failure patients caused by the shortage of donor organs available for transplantation. The optimal selection of the assist device is based on the initial consideration according to hemodynamic situation, comorbidities, intended time of use and therapeutic options. The present article offers an update on currently available mechanical circulatory support systems (MCSS) for short and long-term use as well as an insight into future perspectives.

Resource use trends in extracorporeal membrane oxygenation in adults: an analysis of the Nationwide Inpatient Sample 1998-2009.

OBJECTIVE: The study objective was to determine whether significant trends over time have occurred in resource use associated with the use of extracorporeal membrane oxygenation in critically ill adults. METHODS: All adult admissions involving extracorporeal membrane oxygenation were examined by using the Nationwide Inpatient Sample database (years 1998-2009). Trends in volume, outcome, and resource use (including hospital charges, length of stay, and charges per day) were analyzed. RESULTS: An estimated total of 8753 admissions involved extracorporeal membrane oxygenation over the study period. Overall length of stay was 18.3 ± 1.3 days. Total hospital charges averaged $344,009 ± $30,707 per admission, with average charges per day of $40,588 ± $3099. Cumulative national charges for extracorporeal membrane oxygenation admissions increased significantly from $109.0 million in 1998 to $764.7 million in 2009 (P = .0016). Charges per patient and length of stay also increased significantly (P = .0032 and .0321, respectively). The increasing trend in the number of extracorporeal membrane oxygenation admissions during the study period was not statistically significant (P = .19). The post-cardiotomy group had more favorable outcomes and lower resource use. A shift was observed in the relative case-mix of extracorporeal membrane oxygenation admissions over the study period, with a relative decrease in the post-cardiotomy group and increases in the cardiogenic shock, respiratory failure, and lung transplant groups. CONCLUSIONS: These results suggest that dramatic increases in resource use associated with extracorporeal membrane oxygenation are not solely the result of increased volume, but in part are due to a shift toward extracorporeal membrane oxygenation use in patient groups (other than in the post-cardiotomy setting) with greater resource use and worse outcomes.

[Mobile unit for cardio-respiratory support]. / Unité Mobile d'Assistance circulatoire et respiratoire.

In order to effectively deal with the increase in cardiac and/or respiratory services outside of Lille CHU (University Hospital), an interdisciplinary medical/surgical procedure has been put in place in collaboration with the emergency medical service (SAMU). This organization makes it possible to respond rapidly to a demand outside the University Hospital, while ensuring safe management of patients.

Medical and financial impact of a neonatal extracorporeal membrane oxygenation referral center in the nitric oxide era.

OBJECTIVES: The primary objective of this study was to determine whether widespread use of nitric oxide after Food and Drug Administration approval decreased admissions to a neonatal referral center for extracorporeal membrane oxygenation evaluation. We also sought to determine whether antecedent treatment delayed eventual transfer, resulting in sicker patients, increased mortality, increased extracorporeal membrane oxygenation application, and higher direct costs of care. METHODS: This was a retrospective cohort study of all of the patients transferred to a neonatal referral center for extracorporeal membrane oxygenation evaluation before (1995-1999) and after (2000-2005) Food and Drug Administration approval of nitric oxide. Patients were divided into "congenital diaphragmatic hernia" and "persistent pulmonary hypertension" (all other diagnoses) for additional analysis. RESULTS: Admission rates for extracorporeal membrane oxygenation evaluation decreased in the nitric oxide era, and eventual transfer was not delayed. Persistent pulmonary hypertension patients had improved oxygen indexes, a trend toward decreased mortality, decreased extracorporeal membrane oxygenation use, and decreased direct costs. Congenital diaphragmatic hernia patients had unchanged physiologic measurements, mortality, and extracorporeal membrane oxygenation use with increased direct costs of care. As a whole, outcomes for patients transferred for extracorporeal membrane oxygenation evaluation improved, whereas direct costs were unchanged. CONCLUSIONS: Persistent pulmonary hypertension patients had improved outcomes with decreased costs, whereas congenital diaphragmatic hernia patients had unchanged outcomes with increased costs. Overall, patients admitted to this NICU because of the presence of extracorporeal membrane oxygenation services had improved outcomes without increased costs in the nitric oxide era.

Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement.

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

Pediatric mechanical circulatory support in the United States: past, present, and future.

Mechanical support of the failing myocardium has become standard therapy for adults who fail medical management. Historically, there have been fewer options for children with heart failure. Extracorporeal membrane oxygenation and centrifugal pump-based ventricular assist devices have been the most commonly used circulatory support modalities for pediatrics in the United States. During the last few years, substantial advances in pediatric circulatory support have been made, with greater availability of a number of devices suitable for pediatrics. For example, there has been increasing experience using the DeBakey VAD Child and the Berlin Heart VAD to provide circulatory support for children during this period. A number of innovative devices under development supported by the Pediatric Circulatory Support Program of the National Heart, Lung, and Blood Institute hold great promise for expanded options for pediatric mechanical circulatory support in the future.

Extracorporeal life support: the University of Michigan experience.

The University of Michigan experience with extracorporeal life support (ECLS) in 1000 consecutive patients between 1980 and 1998 is the largest series at one institution in the world. Among this patient population, survival to hospital discharge in moribund patients with respiratory failure was 88% in 586 neonates, 70% in 132 children, and 56% in 146 adults. Survival in moribund patients with cardiac failure was 48% in 105 children and 33% in 31 adults. This article describes the University of Michigan's overall ECLS patient experience, the progression of ECLS from laboratory experiments to clinical application at the bedside, the expansion of the technology to other centers, and current ECLS technology and outcomes. Despite the challenges faced in clinical research in this field, our experience and that of others has shown that ECLS saves lives of patients with acute cardiac or pulmonary failure in a variety of clinical settings.