Application of extracorporeal membrane oxygenation to adults with cardiogenic shock and cardiac arrest in hospital

doi:10.3969/j.issn.1674-8115.2023.12.007

Abstract

Abstract:

Objective ·To assess the effect of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment on the mortality rate of patients suffering from cardiogenic shock and cardiac arrest in hospital. Methods ·A total of 19 patients with cardiogenic shock or cardiac arrest who were treated with VA-ECMO treatment in Suzhou Kowloon Hospital, Shanghai Jiao Tong University School of Medicine from September 2017 to March 2022 were included in the retrospective study. Patients were divided into extracorporeal cardiopulmonary resuscitation (ECPR) group (n=9) and VA-ECMO for cardiogenic shock (E-CS) group (n=10) according to whether cardiac arrest had occurred. The general demographic data, clinical data, Sequential Organ Failure Assessment (SOFA) scores, postoperative complications and prognostic indicators of the two groups of patients were collected. Univariate and multivariate Cox proportional hazard regression analyses were used to evaluate the correlation between each covariate and hospital mortality. Results ·Among the included patients, there were 15 males (78.9%), with an average age of 46.5 (34.5, 61.6) years. The incidence of postoperative complications was as follows: bleeding (47.4%), AKI (36.8%), infection (31.6%), limb ischemia (15.8%) and cerebrovascular accident (5.3%). The duration of VA-ECMO was 4.0 (2.0, 6.8) days, and the intensive care duration was 11.5 (5.8, 26.2) days; the ECMO withdrawal success rate was 63.2%, and the hospital mortality was 63.2%. The results of univariate Cox proportional hazard regression analysis showed that AKI (prior to VA-ECMO initiation), postoperative complications of infection and limb ischemia were correlated with the hospital mortality of patients (all P<0.05). The results of multivariate Cox proportional hazard regression analysis showed that AKI (prior to VA-ECMO initiation), postoperative complications of infection and limb ischemia were also independent risk factors for the hospital mortality of patients (all P<0.05). Conclusion ·For patients with cardiogenic shock and cardiac arrest treated with VA-ECMO, AKI (prior to VA-ECMO initiation), postoperative infection and limb ischemia are independently associated with higher hospital mortality.

Key words: veno-arterial extracorporeal membrane oxygenation (VA-ECMO), extracorporeal cardiopulmonary resuscitation (ECPR), cardiogenic shock (CS), cardiac arrest (CA), hospital mortality

CLC Number:

R654.1

SUI Mingliang, TANG Weibing, WU Changjiang, HUANG Chaofa, YANG Yadi, XIA Damei. Application of extracorporeal membrane oxygenation to adults with cardiogenic shock and cardiac arrest in hospital[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(12): 1529-1534.

Figures/Tables 4

TrendMD

References 10

1	RAO P, KHALPEY Z, SMITH R, et al. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest[J]. Circ Heart Fail, 2018, 11(9): e004905.
2	梁立丰, 张文娟. 预测重症患者院内心脏骤停列线图的建立与验证[J]. 中华急诊医学杂志, 2023, 32(1): 38-45.
	LIANG L F, ZHANG W J. Development and validation of a nomogram to predict in-hospital cardiac arrest in critically ill patients[J]. Chinese Journal of Emergency Medicine, 2023, 32(1): 38-45.
3	COMBES A, PRICE S, SLUTSKY A S, et al. Temporary circulatory support for cardiogenic shock[J]. Lancet, 2020, 396(10245): 199-212.
4	SMITH M, VUKOMANOVIC A, BRODIE D, et al. Duration of venoarterial extracorporeal life support (VA-ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry[J]. Crit Care, 2017, 21(1): 45.
5	VAKIL D, SOTO C, D′COSTA Z, et al. Short-term and intermediate outcomes of cardiogenic shock and cardiac arrest patients supported by venoarterial extracorporeal membrane oxygenation[J]. J Cardiothorac Surg, 2021, 16(1): 290.
6	KAUSHAL M, SCHWARTZ J, GUPTA N, et al. Patient demographics and extracorporeal membranous oxygenation (ECMO)-related complications associated with survival to discharge or 30-day survival in adult patients receiving venoarterial (VA) and venovenous (VV) ECMO in a quaternary care urban center[J]. J Cardiothorac Vasc Anesth, 2019, 33(4): 910-917.
7	COMBES A, LEPRINCE P, LUYT C E, et al. Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock[J]. Crit Care Med, 2008, 36(5): 1404-1411.
8	赵帅. VA-ECMO辅助心脏重症患者的临床结局及早期死亡危险因素分析[D]. 北京: 北京协和医学院, 2021.
	ZHAO S. Analysis of clinical outcomes and risk factors for early mortality in patients with sever cardiac disease assisted by VA-ECMO[D]. Beijing: Peking Union Medical College, 2021.
9	CELIŃSKA-SPODAR M, KUŚMIERCZYK M, ZIELIŃSKI T, et al. Current applications and outcomes of venoarterial extracorporeal membrane oxygenation based on 6 years of experience: risk factors for in‑hospital mortality[J]. Pol Arch Intern Med, 2021, 131(12): 16145.
10	陈晓华, 陈俊宇, 王润东, 等. 行体外心肺复苏的院内心搏骤停患者使用主动脉内球囊反搏与住院死亡关系的研究: 一项基于文献数据的二次分析[J]. 中华危重病急救医学, 2022, 34(3): 269-273.
	CHEN X H, CHEN J Y, WANG R D, et al. Relationship of in-hospital mortality and using intra-aortic balloon pump with extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest: a secondary analysis based on literature data[J]. Chinese Critical Care Medicine, 2022, 34(3): 269-273.

Item	Total (n=19)	E-CS group (n=10)	ECPR group (n=9)
Age/year	46.5 (34.5, 61.6)	50.8 (37.2, 63.5)	43.6 (31.6, 59.8)
Male/n(%)	15 (78.9)	8 (80.0)	7 (77.8)
BMI/(kg·m^-2)	22.3±2.4	22.5±2.8	22.1±1.9
Previous underlying diseases/n(%)
Diabetes	4 (21.1)	2 (20.0)	2 (22.2)
Hypertension	5 (26.3)	4 (40.0)	1 (11.1)
Hyperlipidemia	2 (10.5)	1 (10.0)	1 (11.1)
Chronic heart failure	3 (15.8)	1 (10.0)	2 (22.2)
Coronary artery disease	6 (31.6)	5 (50.0)	1 (11.1)
Chronic kidney disease	3 (15.8)	2 (20.0)	1 (11.1)
Etiology of CS and CA/n(%)
Acute myocardial infarction	8 (42.2)	4 (40.0)	4 (44.4)
Acute severe myocarditis	3 (15.8)	1 (10.0)	2 (22.2)
Heart failure	7 (36.8)	4 (40.0)	3 (33.3)
Cardiomyopathy	1 (5.3)	1 (10.0)	0 (0)
Combined IABP treatment/n(%)	6 (31.6)	2 (20.0)	4 (44.4)
ECMO tube placement time/min	33.8 (25.5, 44.3)	38.5 (27.8, 48.2)	31.5 (25.3, 42.9)
D to I time/min	79.5 (45.8, 98.2)	86.5 (51.3, 116.2)	76.7 (43.5, 96.9)
Before ECMO initiation
Lactic acid level/(mmol·L^-1)	10.7±4.0	10.2±4.9	11.1±2.8
AKI/n(%)	11 (57.9)	7 (70.0)	2 (22.2)
CRRT/n(%)	6 (31.6)	4 (40.0)	2 (22.2)
Ventilator support/n(%)	16 (84.2)	9 (90.0)	9 (100.0)
24 h LCR after ECMO initiation/%	67.0 (58.2, 76.3)	63.6 (49.7, 74.6)	69.2 (57.5, 83.4)
Duration of VA-ECMO/d	4.0 (2.0, 6.8)	3.9 (2.5, 5.8)	4.5 (2.6, 6.5)
ECMO withdrawal success rate/n(%)	12 (63.2)	7 (70.0)	5 (55.6)
Intensive care duration/d	11.5 (5.8, 26.2)	10.2 (3.8, 24.5)	11.8 (4.1, 28.0)
Hospital mortality/n(%)	12 (63.2)	7 (70.0)	5 (55.6)
DDCEW/n(%)	5 (26.3)	4 (40.0)	1 (11.1)
SOFA scores/score	14.2±3.7	13.8±4.5	14.8±4.5

Item	Total (n=19)	E-CS group (n=10)	ECPR group (n=9)
Age/year	46.5 (34.5, 61.6)	50.8 (37.2, 63.5)	43.6 (31.6, 59.8)
Male/n(%)	15 (78.9)	8 (80.0)	7 (77.8)
BMI/(kg·m^-2)	22.3±2.4	22.5±2.8	22.1±1.9
Previous underlying diseases/n(%)
Diabetes	4 (21.1)	2 (20.0)	2 (22.2)
Hypertension	5 (26.3)	4 (40.0)	1 (11.1)
Hyperlipidemia	2 (10.5)	1 (10.0)	1 (11.1)
Chronic heart failure	3 (15.8)	1 (10.0)	2 (22.2)
Coronary artery disease	6 (31.6)	5 (50.0)	1 (11.1)
Chronic kidney disease	3 (15.8)	2 (20.0)	1 (11.1)
Etiology of CS and CA/n(%)
Acute myocardial infarction	8 (42.2)	4 (40.0)	4 (44.4)
Acute severe myocarditis	3 (15.8)	1 (10.0)	2 (22.2)
Heart failure	7 (36.8)	4 (40.0)	3 (33.3)
Cardiomyopathy	1 (5.3)	1 (10.0)	0 (0)
Combined IABP treatment/n(%)	6 (31.6)	2 (20.0)	4 (44.4)
ECMO tube placement time/min	33.8 (25.5, 44.3)	38.5 (27.8, 48.2)	31.5 (25.3, 42.9)
D to I time/min	79.5 (45.8, 98.2)	86.5 (51.3, 116.2)	76.7 (43.5, 96.9)
Before ECMO initiation
Lactic acid level/(mmol·L^-1)	10.7±4.0	10.2±4.9	11.1±2.8
AKI/n(%)	11 (57.9)	7 (70.0)	2 (22.2)
CRRT/n(%)	6 (31.6)	4 (40.0)	2 (22.2)
Ventilator support/n(%)	16 (84.2)	9 (90.0)	9 (100.0)
24 h LCR after ECMO initiation/%	67.0 (58.2, 76.3)	63.6 (49.7, 74.6)	69.2 (57.5, 83.4)
Duration of VA-ECMO/d	4.0 (2.0, 6.8)	3.9 (2.5, 5.8)	4.5 (2.6, 6.5)
ECMO withdrawal success rate/n(%)	12 (63.2)	7 (70.0)	5 (55.6)
Intensive care duration/d	11.5 (5.8, 26.2)	10.2 (3.8, 24.5)	11.8 (4.1, 28.0)
Hospital mortality/n(%)	12 (63.2)	7 (70.0)	5 (55.6)
DDCEW/n(%)	5 (26.3)	4 (40.0)	1 (11.1)
SOFA scores/score	14.2±3.7	13.8±4.5	14.8±4.5

Item	Total (n=19)	E-CS group (n=10)	ECPR group (n=9)
Postoperative complication/n(%)
Bleeding	9 (47.4)	4 (40.0)	5 (55.6)
Infection	6 (31.6)	3 (30.0)	3 (33.3)
AKI	7 (36.8)	3 (20.0)	4 (44.4)
Limb ischemia	3 (15.8)	2 (20.0)	1 (11.1)
Cerebrovascular accident	1 (5.3)	1 (10.0)	0 (0)
Prognostic indicator/n(%)
CPC 1 to 2 grade	10 (52.6)	5 (50.0)	5 (55.6)
Survival discharge	7 (36.8)	3 (30.0)	4 (44.4)
First year survival rate	4 (21.1)	1 (10.0)	3 (33.3)

Item	Total (n=19)	E-CS group (n=10)	ECPR group (n=9)
Postoperative complication/n(%)
Bleeding	9 (47.4)	4 (40.0)	5 (55.6)
Infection	6 (31.6)	3 (30.0)	3 (33.3)
AKI	7 (36.8)	3 (20.0)	4 (44.4)
Limb ischemia	3 (15.8)	2 (20.0)	1 (11.1)
Cerebrovascular accident	1 (5.3)	1 (10.0)	0 (0)
Prognostic indicator/n(%)
CPC 1 to 2 grade	10 (52.6)	5 (50.0)	5 (55.6)
Survival discharge	7 (36.8)	3 (30.0)	4 (44.4)
First year survival rate	4 (21.1)	1 (10.0)	3 (33.3)

Item	B	S.E	Wald	P value	HR (95.0% CI)
Primary outcome
Age	0.053	0.058	0.833	0.361	1.054 (0.941‒1.181)
BMI	-0.001	0.242	0.000	0.998	0.999 (0.621‒1.607)
SOFA scores	0.011	0.064	0.027	0.868	1.011 (0.891‒1.147)
ECMO tube placement time	0.032	0.028	1.358	0.244	1.033 (0.978‒1.091)
D to I time	-0.005	0.012	0.194	0.659	0.995 (0.972‒1.108)
Lactic acid level before ECMO initiation	-0.172	0.155	1.232	0.267	0.842 (0.622‒1.141)
24 h LCR after ECMO initiation	0.179	3.937	0.191	0.662	0.179 (0.001‒401.203)
Combined IABP treatment	-3.749	2.122	3.120	0.077	0.024 (0.000‒1.508)
AKI (prior to ECMO initiation)	3.400	1.606	4.484	0.034	29.960 (1.288‒697.195)
Postoperative infection	3.612	1.395	6.706	0.010	37.028 (2.406‒569.790)
Postoperative bleeding	1.042	1.120	0.867	0.062	2.835 (0.316‒25.444)
Postoperative limb ischemia	3.290	1.378	5.706	0.017	6.853 (1.805‒399.524)
Previous underlying diseases	1.739	1.952	0.794	0.373	5.693 (0.124‒260.970)
Secondary outcome
Age	-2.027	1.017	3.973	0.047	1.007 (0.973‒1.041)
BMI	-0.007	0.140	0.002	0.962	0.993 (0.755‒1.308)
SOFA scores	0.067	0.080	0.760	0.401	1.069 (0.915‒1.250)
ECMO tube placement time	0.019	0.035	0.287	0.592	1.019 (0.951‒1.092)
D to I time	0.001	0.010	0.023	0.880	1.001 (0.982‒1.021)
Lactic acid level before ECMO initiation	-0.034	0.101	0.110	0.741	0.967 (0.793‒1.179)
24 h LCR after ECMO initiation	-4.779	2.843	2.849	0.091	0.008 (0.000‒2.168)
Combined IABP treatment	2.395	0.821	8.510	0.041	1.674 (1.164‒4.769)
AKI (prior to ECMO initiation)	-2.154	1.023	4.433	0.036	1.857 (1.105‒8.023)
Postoperative infection	0.063	0.734	0.736	0.391	1.877 (0.445‒7.910)
Postoperative bleeding	-0.360	0.714	0.241	0.624	0.698 (0.166‒2.940)
Postoperative limb ischemia	1.498	1.416	1.118	0.290	4.472 (0.279‒71.807)
Previous underlying diseases	0.122	0.731	0.028	0.867	1.130 (0.270‒4.738)