Risk Factors of Bleeding in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly being used for circulatory shock. Bleeding is a frequent complication and is associated with increased mortality. The purpose of our study was to identify factors associated with early major bleeding after VA ECMO initiation. METHODS: We performed a retrospective observational study based on our database. In accordance with the Extracorporeal Life Support Organization definition, the population was divided in two groups: major bleeding events (group B) and no major bleeding events (group O). We collected data on all major bleeding events occurring during the first 48 hours after VA ECMO initiation. RESULTS: Of the 243 patients analyzed, 111 patients (46%) had an early major bleeding event. Independent risk factors associated with early major bleeding events were postcardiotomy VA ECMO (odds ratio [OR] 1.98; 95% confidence interval [CI], 1.08 to 3.62; P = .02), body mass index (OR 0.91; 95% CI, 0.85 to 0.98; P = .01), hemoglobinemia (OR 0.8; 95% CI, 0.7 to 0.92; P = .002), fibrinogen (OR 0.67; 95% CI, 0.52 to 0.84; P = .001), and pH (OR 0.15; 95% CI, 0.02 to 1.04; P = .05). By using a receiver-operating characteristics curve analysis, hemoglobin level less than 9 g dL-1, fibrinogen level less than 2 g L-1, pH lower than 7.12, and body mass index below 25 kg/m2 were identified to predict early major bleeding events. Major bleeding events were independently associated with mortality (OR 2.54; CI 95%, 1.38 to 4.66; P = .01). CONCLUSIONS: We found that postcardiotomy VA ECMO, hemoglobin levels less than 9 g dL-1, fibrinogen levels less than 2 g L-1, pH lower than 7.12, and body mass index below 25 kg/m2 were associated with a higher risk for early major bleeding events.

Prognosis Value of Early Veno Arterial PCO2 Difference in Patients Under Peripheral Veno Arterial Extracorporeal Membrane Oxygenation.

INTRODUCTION: Veno arterial membrane oxygenation (VA ECMO) is increasingly used for cardiogenic failure. However, hemodynamic targets for adequate resuscitation remain a challenge. The PCO2 gap and the ratio between PCO2 gap and the arteriovenous difference in oxygen (PCO2 gap/Da-vO2) are marker of peripheral hypoperfusion. We hypothesized that the PCO2 gap and the PCO2 gap/Da-vO2 ratio might be useful parameters in VA ECMO patients. PATIENTS AND METHODS: We conducted an observational prospective study between September 2015 and February 2017. All consecutive patients >18 years of age who had been treated with peripheral VA ECMO for cardiac failure were included. We compared two groups of patients: patients who died of any cause under VA ECMO or in the 72 h following VA ECMO weaning (early death group)-and patients who survived VA ECMO weaning more than 72 h (surviving group). Blood samples were drawn from arterial and venous VA ECMO cannulas at H0, H6, and H24. The ability of PCO2 gap and PCO2 gap/Da-vO2 to discriminate between early mortality and surviving was studied using receiver operating characteristic curves analysis. RESULTS: We included 20 patients in surviving group and 29 in early death group. The PCO2 gap was higher in the early death group at H6 (7.4 mm Hg [5.7-10.1] vs. 5.9 mm Hg [3.8-9.2], P < 0.01). AUC for PCO2 gap at H6 was 0.76 (0.61-0.92), with a cutoff of 6.2 mm Hg. The PCO2 gap/Da-vO2 was higher in the early death group at H0 (2.1 [1.5-2.6] vs. 1.2 [0.9-2.4], P < 0.01) and at H6 (2.1 [1.3-2.6] vs. 1.0 [0.8-1.7], P < 0.01). AUC for PCO2 gap/Da-vO2 at H0 and H6 were 0.79 and 0.73 respectively; the cut-off value was 1.4. CONCLUSIONS: Early PCO2 gap and PCO2 gap/Da-vO2 ratio are higher in the early death group in patients under VA ECMO.

A single dose of tramadol in continuous wound analgesia with levobupivacaine does not reduce post-sternotomy pain: a randomized controlled trial.

BACKGROUND: Medial sternotomy is commonly used in cardiac surgery, although it results in intense post-operative pain. The placement of a sternal wound catheter for the administration of local anesthetic represents an effective technique. An initial bolus of tramadol in the sternal wound catheter could potentiate the effect of the local anesthetic and decrease both the post-operative pain and the morphine consumption. PATIENTS AND METHODS: We conducted a prospective, randomized, double-blind study at the University Hospital Center, Dijon, France. Patients requiring scheduled or non-extreme emergency surgery for valve disease, aorta disease, atrial myxoma, or coronary artery bypass graft via sternotomy were included. A sternal wound catheter was inserted at the end of the surgery. The patients were randomized to receive either a 2 mg/kg bolus of tramadol (n=80) or a placebo (n=80) in the wound catheter. The bolus administration was followed by a continuous infusion of 1.25% levobupivacaine for the first 48 hrs following surgery. The patients' morphine consumption during the first 48 hrs after extubation was recorded. The other investigated variables were the patients' rescue analgesia, arterial blood gasses, and length of stay in the intensive care unit and in hospital, as well as the incidence of chronic pain at the four-month follow-up point. RESULTS: The morphine consumption was found to be comparable in the two groups (38 mg vs 32 mg, p=0.102). No effect was found in terms of the arterial blood gasses, lengths of stay, or incidence of chronic pain. CONCLUSION: The addition of tramadol to the local anesthetic delivered via a wound catheter following sternotomy did not reduce the patients' post-operative morphine consumption. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02851394.

Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study.

BACKGROUND: No study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course. METHODS: After retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS). RESULTS: One hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6-34) vs 5 mg (2-18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66-115) vs 77 mmol/l (IQR: 69-95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1-5) vs 5 (3-6) hours, p = 0.001 and 2 (1-3) vs 3 (2-5) days, p = 0.037). CONCLUSION: The use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results. TRIAL REGISTRATION: This study was retrospectively registered to ct2 (identifier: NCT03816592 ) on January 25, 2019.

Extubation of patients undergoing extracorporeal life support. A retrospective study.

INTRODUCTION: The use of extracorporeal life support (ECLS) is increasing worldwide, in particular for the management of refractory cardiac arrest, cardiogenic shock and post cardiopulmonary bypass ventricular failure. Extubation of patients under extracorporeal membrane oxygenation (ECMO) for respiratory failure is a growing practice for adult and pediatric patients, especially for lung transplantation candidates. Because of potential complications and, specifically, accidental arterial decannulation, extubation of patients under ECLS is not standard practice. Our goal was to evaluate the interest in patient extubation under ECLS. MATERIALS AND METHODS: We performed a monocentric, retrospective study of all ECLS cases between January 2014 and January 2016. We excluded patients who died within the first 48 hours of ECLS. RESULTS: We analyzed 57 of the initial 109 patients included in the study. The initial SOFA score was higher in the non-extubated group under ECLS, without significant difference (8.6 ± 2.8 vs 7.2 ± 2.1, p=0.065). Patients who were not extubated had a higher rate of acquired ventilator pneumonia (61.9% vs 26.7%, p=0.03). Moreover, patients who were extubated under ECLS had better 30-day survival rates (73.3% vs 40.5%, p=0.04). In multivariate analyses, the independent factors associated with mortality were age, duration of ECLS and the lack of extubation under ECLS. CONCLUSION: Extubation of patients under ECLS is safe and feasible. Furthermore, in extubated patients, we observed fewer cases of ventilator-associated pneumonia and better 30-day survival rates.

Comparable Outcome of Out-of-Hospital Cardiac Arrest and In-Hospital Cardiac Arrest Treated With Extracorporeal Life Support.

Extracorporeal life support (ECLS) has shown benefits in the management of refractory in-hospital cardiac arrest (IHCA) by improving survival. Nonetheless, the results concerning out-of-hospital refractory cardiac arrests (OHCA) remain uncertain. The aim of our investigation was to compare survival between the two groups. We realized a single-center retrospective, observational study of all patients who presented IHCA or OHCA treated with ECLS between 2011 and 2015. Multivariate analysis was realized to determine independent factors associated with mortality. Over the 4-year period, 65 patients were included, 43 in the IHCA group (66.2%), and 22 (33.8%) in the OHCA group. The duration of low flow was significantly longer in the OHCA group (60 vs. 90 min, P = 0.004). Survival to discharge from the hospital was identical in the two groups (27% in the OHCA group vs. 23% in the IHCA group, P = 0.77). All surviving patients in the OHCA group had a cerebral performance categories score of 1-2. In multivariate analysis, we found that the initial lactate level and baseline blood creatinine were independently associated with mortality. We found comparable survival and neurological score in patients who presented IHCA and OHCA treated with ECLS. We believe that appropriate selection of patients and optimization of organ perfusion during resuscitation can lead to good results in patients with OHCA treated with ECLS.