Restrictive and liberal transfusion strategies in extracorporeal membrane oxygenation: A retrospective observational study.

BACKGROUND: To compare the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive transfusion strategy with those who had a liberal strategy. STUDY DESIGN AND METHODS: We retrospectively reviewed all adult patients from 2010 to 2019 who received a minimum of one packed red blood cell (pRBC) during ECMO. Hemoglobin values before each transfusion were retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤8.5 g/dl in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold >8.5 g/dl in any transfusion episode. RESULTS: The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group. The median hemoglobin level, taking into account all measured hemoglobin values, during ECMO support was 8.3 and 9.9 g/dl, and the average units of pRBC received per day were 0.7 (0.3-1.8) and 1.2 (0.6-2.3), respectively. There were no significant differences in intensive care unit (ICU) mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56-1.30; p = .47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52-1.21; p = .28), and 90-day mortality (adjusted OR, 0.84; 95% CI 0.55-1.28; p = .42) between the two groups. Among subgroup analyses, a restrictive transfusion strategy was associated with decreased risk of ICU mortality in patients on veno-venous ECMO (adjusted OR, 0.36; 95% CI 0.17-0.73; p = .005). There was no heterogeneity on outcomes across patients stratified by age, APACHE IV score, or need for large volume transfusion. DISCUSSION: Our data suggested it may be safe to adopt a restrictive red cell transfusion threshold of 8.5 g/dl in patients on ECMO, and highlighted the need for prospective trials in this heavily-transfused population.

Effect of hospital case volume on clinical outcomes of patients requiring extracorporeal membrane oxygenation: a territory-wide longitudinal observational study.

Background: The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable. Methods: All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. "High-volume" centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while "low-volume" centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers. Results: A total of 911 patients received extracorporeal membrane oxygenation-297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61-1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54-1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46). Conclusions: In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.

Comparing the outcomes of bedside percutaneous VA-ECMO decannulation by ProGlide and Manta in a high-ECMO-volume center in Hong Kong.

BACKGROUND: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation with different percutaneous closure devices has been increasing. At our center, ProGlide devices have been used since November 2018, and Manta devices became an alternative since March 2020. This study aimed to compare the success and complication rates and the clinical outcomes of ProGlide and Manta devices for VA-ECMO decannulation after arteriotomy wound closure. METHODS: We retrospectively reviewed the results of bedside VA-ECMO decannulation between November 2018 and June 2021. Patients with VA-ECMO who could be bridged to recovery were recruited and divided into the ProGlide or Manta group based on the closure device used. Procedure time, amount of blood loss, amount of blood products transfused, and use of vasoactive medications during the procedure were documented. Clinical examination and Doppler ultrasound were performed to detect any complications. RESULTS: After the closure technique, ProGlide was used in 44 patients and Manta was used in 13. There was no significant difference in the success rate between the ProGlide and Manta groups (86.4% vs. 100%). Amount of blood loss was greater in the ProGlide group than in the Manta group (290 [100-400] ml vs. 50 [50-100] ml), and more patients in the ProGlide group required an increased dose of inotropes during the procedure (59.1% vs. 15.4%), but the transfusion requirement was similar between the two groups. CONCLUSIONS: The success rate of hemostasis using arteriotomy wound closure during VA-ECMO decannulation was similar between the two devices.

Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018.

BACKGROUND: Globally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong. METHODS: This was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed. RESULTS: From 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by - 0.15 (95% CI - 0.18 to - 0.11) per year (Pearson's R = - 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer-Lemeshow test p < 0.001). CONCLUSIONS: Despite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong.

Case report of successful peripheral veno-arterial extracorporeal membrane oxygenation in a patient with chronic type B aortic dissection.

A case report of successful application of peripheral veno-arterial extracorporeal membrane oxygenation in a patient with chronic type B aortic dissection and myocardial stunning to bridge to recovery was presented. Good outcomes from the application of peripheral veno-arterial extracorporeal membrane oxygenation in aortic dissection have rarely been reported, and the considerations of starting veno-arterial extracorporeal membrane oxygenation in this situation were seldom discussed. The orthodox that peripheral veno-arterial extracorporeal membrane oxygenation is an absolute contraindication for initiation of peripheral veno-arterial extracorporeal membrane oxygenation should be challenged. With proper planning and real-time transesophageal echocardiography-guided cannulation, peripheral veno-arterial extracorporeal membrane oxygenation is possibly beneficial. The considerations and echocardiography-guided techniques would be discussed in this report.

Enhanced vascular assessment by ultrasound using microbubble contrast after percutaneous decannulation of peripheral veno-arterial extracorporeal membrane oxygenation.

Termination of peripheral veno-arterial extracorporeal membrane oxygenation support by managing the arteriotomy wound using a percutaneous closure device was reported successful and effective. However, careful assessment by clinical examination and also ultrasound Doppler assessment of the lower limb vasculature after closure is of paramount importance. Complications including pseudoaneurysm, arterial stenosis, and acute thrombosis are not uncommon. In this case report, commercial microbubbles were used as ultrasound contrast to enhance the image quality for better vascular ultrasound and Doppler assessment after veno-arterial extracorporeal membrane oxygenation percutaneous decannulation. A peudoaneurysm was revealed after microbubble injection, which would otherwise be missed.

Real-time ultrasound-guided bedside closure of arteriotomy wound using MANTA closure device during venoarterial extracorporeal membrane oxygenation decannulation.

Percutaneous closure of arteriotomy wound during peripheral venoarterial extracorporeal membrane oxygenation decannulation was shown to be safe and allow earlier mobilization. The new MantaTM vascular closure device (Essential Medical), designed for the closure of arterotomy wound created by large-bore vascular sheaths up to 25Fr during endovascular catheterization procedures, was reported to be applicable in venoarterial extracorporeal membrane oxygenation decannulation. In this article, we would like to share our experience of using real-time ultrasound guidance to ensure the safe application of Manta during bedside venoarterial extracorporeal membrane oxygenation decannulation.

One-year experience of bedside percutaneous VA-ECMO decannulation in a high-ECMO-volume center in Hong Kong.

BACKGROUND: When veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support can be terminated, open repair of arteriotomy wounds in operating theaters is the standard of practice. Comparable outcomes by percutaneous decannulation using different closure devices have been reported. However, transport of the critically- ill, man-power and timeslots of operating theaters could be saved if decannulation was performed at bedside. METHOD: Bedside percutaneous arteriotomy wound closure became our default method of decannulation since November 2018. We reviewed our 1-year data to evaluate if such practice could be safely adopted in a local high-ECMO-volume center. RESULTS: Between November 2018 and October 2019, 25 patients had their VA-ECMO terminated at the bedside. Twenty-one patients (84%) had successful decannulation. For those who failed, emergency open repair resulted in no additional complications. Two ProGlide devices were used in 15 (71.4%) patients and three were used in 6 (28.6%) patients. The procedure time was 27 (15-45) min. The median blood loss was 300 mL (250-400). Minor complications were found in 4 (19.1%) patients, including two arterial clot formation, one pseudoaneurysm and one wound infection. There were no other major complications. CONCLUSION: Our 1-year experience showed that percutaneous bedside VA-ECMO decannulation was feasible to commence in a local large-ECMO-volume center.

Confirming Distal Perfusion Catheter Position by Micro-bubbles in Patients on Peripheral Venoarterial Extracorporeal Membrane Oxygenation.

Distal perfusion catheter (DPC) is commonly employed to prevent lower limb ischemia in patient put on peripheral venoarterial extracorporeal membrane oxygenation. Confirming its proper position is important but technically difficult by bedside ultrasound. We describe in this article a novel method to use micro-bubble ultrasound enhancing agents, which are commonly used for contrast echocardiography studies, to confirm DPC position at the bedside. The sequential appearance of the micro-bubbles in the popliteal artery and then popliteal vein by ultrasound after injection through the side port of the DPC confirms the proper DPC position.