RBC Transfusion in Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study.

OBJECTIVES: In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation. DESIGN: Mixed method approach combining multicenter retrospective study and survey. SETTING: Sixteen ICUs worldwide. PATIENTS: Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients. CONCLUSIONS: Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.

Assessment of a standardized EEG reactivity protocol after cardiac arrest.

OBJECTIVE: Reactivity assessment during EEG might provide important prognostic information in post-anoxic coma. It is still unclear how best to perform reactivity testing and how it might be affected by hypothermia. Our primary aim was to determine and compare the effectiveness, inter-rater reliability and prognostic value of different types of stimulus for EEG reactivity testing, using a standardized stimulation protocol and standardized definitions. Our secondary aims were to assess the effect of hypothermia on these measures, and to determine the prognostic value of a simplified sequence with the three most efficient stimuli. METHODS: Prospective single-center cohort of post-anoxic comatose patients admitted to the intensive care unit of an academic medical center between January 1, 2016 and December 31, 2018 and receiving continuous EEG monitoring (CEEG). Reactivity was assessed using standardized definitions and standardized sequence of stimuli: auditory (mild noise and loud noise), tactile (shaking), nociceptive (nostril tickling, trapezius muscle squeezing, endotracheal tube suctioning), and visual (passive eye opening). Gwet's AC1 and percent agreement (PA) were used to measure inter-rater agreement (IRA). Ability to predict favorable neurological outcome (defined as a Cerebral Performance Category of 1 to 2: no disability to moderate disability) was measured with sensitivity (Se), specificity (Sp), accuracy, and odds ratio [OR]. These were calculated for each stimulus type and at the level of the entire sequence comprising all the stimuli. RESULTS: One-hundred and fifteen patients were included and 242 EEG epochs were analyzed. Loud noise, shaking and trapezius muscle squeezing most frequently elicited EEG reactivity (42%, 38% and 38%, respectively) but were all inferior to the entire sequence, which elicited reactivity in 58% cases. The IRA for reactivity to individual stimuli varied from moderate to good (AC1:58-69%; PA:56-68%) and was the highest for loud noise (AC1:69%; PA:68%), trapezius muscle squeezing (AC1:67%; PA:65%) and passive eye opening (AC1:68%; PA:64%). Mild (odds ratio [OR]:11.0; Se:70% and Sp:86%) and loud noises (OR:27.0; Se:73% and Sp:75%), and trapezius muscle squeezing (OR:15.3; Se:76% and Sp:83%) during hypothermia had the best predictive value for favorable neurological outcome, although each was inferior to the whole sequence (OR:60.2; Se:91% and Sp:73%). A simplified sequence of loud noise, shaking and trapezius muscle squeezing had the same performance for predicting neurological outcome as the entire sequence. Hypothermia did not significantly affect the effectiveness of stimulation, but IRA was slightly better during hypothermia, for all stimuli. Similarly, the predictive value was higher during hypothermia than during normothermia. CONCLUSIONS: Despite a standardized stimulation protocol and standardized definitions, the IRA of EEG reactivity testing in post-anoxic comatose patients was only good at best (AC1 < 70%), and its predictive value for neurological outcome remained imperfect, in particular with Sp values < 90%. While no single stimulus appeared superior to others, a full sequence using all stimuli or a simplified sequence comprising loud noise, shaking and trapezius muscle squeezing had the best combination of IRA and predictive value. SIGNIFICANCE: This study stresses the necessity to use multiple stimulus types to improve the predictive value of reactivity testing in post-anoxic coma and confirms that it is not affected by hypothermia.

The Impact of Renal Failure and Renal Replacement Therapy on Outcome During Extracorporeal Membrane Oxygenation Therapy.

Acute kidney injury (AKI) is common in patients treated with veno-arterial (VA-) or veno-venous (VV-) extracorporeal membrane oxygenation (ECMO). In this setting, the use of continuous renal replacement therapy (CRRT) can help to optimize fluid status but may also negatively impact on patients' outcome. In contrast, the relationship between AKI, CRRT, and survival in critically ill adult patients receiving ECMO is not well defined. The institutional ECMO database (n = 162) from November 2008 to December 2013, excluding patients with ICU survival <24 hours was reviewed. Demographics, co-morbidities, and concomitant therapies for all patients were collected. AKI was defined according to the Acute Kidney Injury Network (AKIN) criteria. ICU mortality was noted. Data were retrieved for 135 patients (79 with VA-ECMO and 56 with VV-ECMO). Of these, 95 developed AKI, 63 (47%) of whom required CRRT; thus three groups of patients were identified: (a) no AKI; (b) AKI without CRRT (AKINOCRRT ); and (c) CRRT with AKI (AKICRRT ). AKINOCCRT patients were more likely to have preexisting heart disease, to be more severely ill, and to be treated with VA-ECMO than those without AKI. AKICRRT patients were also more likely to be treated with VA-ECMO, had more organ dysfunction at the time of ECMO insertion, and needed more transfusions and inotropic agents than patients without AKI. ICU mortality was 53% (72/135) and was similar in the three groups, even when different AKI stages or VA/VV-ECMO were analyzed separately. In this study, the use of CRRT was not associated with an increased mortality in an adult population of patients treated with ECMO, even after adjustment for confounders.