HEROES V-V-HEmorRhagic cOmplications in Veno-Venous Extracorporeal life Support-Development and internal validation of multivariable prediction model in adult patients.

BACKGROUND: During extracorporeal life support (ECLS), bleeding is one of the most frequent complications, associated with high morbidity and increased mortality, despite continuous improvements in devices and patient care. Risk factors for bleeding complications in veno-venous (V-V) ECLS applied for respiratory support have been poorly investigated. We aim to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving V-V ECLS support. METHODS: Data from adult patients reported to the extracorporeal life support organization (ELSO) registry between the years 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-V ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the predictive model. The performance of the model was tested by discriminative ability and calibration with receiver operating characteristic curves and visual inspection of the calibration plot. RESULTS: In total, 18 658 adult patients were included, of which 3 933 (21.1%) developed bleeding complications. The prediction model showed a prediction of bleeding complications with an AUC of 0.63. Pre-ECLS arrest, surgical cannulation, lactate, pO2 , HCO3 , ventilation rate, mean airway pressure, pre-ECLS cardiopulmonary bypass or renal replacement therapy, pre-ECLS surgical interventions, and different types of diagnosis were included in the prediction model. CONCLUSIONS: The model is based on the largest cohort of V-V ECLS patients and reveals the most favorable predictive value addressing bleeding events given the predictors that are feasible and when compared to the current literature. This model will help identify patients at risk of bleeding complications, and decision making in terms of anticoagulation and hemostatic management.

Quality of life following adult veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used successfully for the past decade in adult patients with acute respiratory distress syndrome (ARDS) refractory to conventional ventilatory support. However, knowledge of the health-related quality of life (HRQoL) in VV-ECMO patients is still limited. Thus, this study aimed to provide a comprehensive overview of the HRQoL following VV-ECMO support in ARDS patients. METHODS: A systematic search was performed on PubMed and Web of Science databases from January 1st, 2009 to October 19th, 2020. Studies reporting on HRQoL following VV-ECMO for ARDS in adults were included. Two authors independently selected studies, extracted data, and assessed methodological quality. RESULTS: Eight studies were eligible for inclusion, consisting of seven observational studies and one randomized controlled trial (total N = 441). All eight studies had a quantitative design and reported 265 VV-ECMO survivors to have a reduced HRQoL compared to a generally healthy population. Follow-up time varied between six months to three years. Additionally, only four studies (total N = 335) compared the HRQoL of VV-ECMO (N = 159) to conventionally treated survivors (N = 176), with one study showing a significantly better HRQoL in VV-ECMO survivors, while three studies were stating comparable HRQoL across groups. Notably, most survivors in these studies appeared to experience varying degrees of anxiety, depression, and post-traumatic stress disorder (PTSD). CONCLUSIONS: ARDS survivors supported by VV-ECMO have a decline in HRQoL and suffered from physical and psychological impairments. This HRQoL reduction is comparable or even better to the HRQoL in conventionally treated ARDS survivors.

Veno-venous extracorporeal life support for blastomycosis-associated acute respiratory distress syndrome.

BACKGROUND: Blastomyces is a dimorphic fungus endemic to regions of North America, which can lead to pneumonia and fatal severe acute respiratory diseases syndrome in up to 89% of patients. Extracorporeal life support can provide adequate oxygenation while allowing the lungs to rest and heal, which might be an ideal therapy in this patient group, although long-term clinical and radiological outcomes are not known. CLINICAL FEATURES: We report on five consecutive patients admitted to Toronto General Hospital intensive care unit between January 2012 and September 2016, with progressive respiratory failure requiring veno-venous extracorporeal life support within 24-96 hours following mechanical ventilation. Ultra-lung protective mechanical ventilation was achieved within 24 hours. Recovery was the initial goal in all patients. Extracorporeal life support was provided for a prolonged period (up to 49 days), and four patients were successfully discharged from the intensive care unit. Long-term radiological assessment in three patients showed major improvement within 2 years of follow-up with some persistent disease-related changes (bronchiectasis, fibrosis, and cystic changes). In two patients, long-term functional and neuropsychological outcomes showed similar limitations to what is seen in acute respiratory distress syndrome patients who are not supported with extracorporeal life support and in acute respiratory distress syndrome patients without blastomycosis, but worse pulmonary function outcomes in the form of obstructive and restrictive changes that correlated with the radiological imaging. CONCLUSION: Veno-venous extracorporeal life support can effectively provide prolonged support for patients with blastomycosis-associated acute respiratory distress syndrome that is safe and associated with favorable long-term outcomes.