Dataset Information

Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation.

ABSTRACT:

Objective

As survival with extracorporeal membrane oxygenation (ECMO) therapy improves, it is important to study patients who do not survive secondary to withdrawal of life-sustaining therapy (WLST). The purpose of the present study was to determine the population and clinical characteristics of those who experienced short latency to WLST.

Design

Retrospective cohort study.

Setting

Single academic hospital center.

Participants

Adult ECMO patients.

Interventions

None.

Measurements and main results

During the study period, 150 patients (mean age 54.8 ± 15.9 y, 43.3% female) underwent ECMO (80% venoarterial ECMO and 20% venovenous ECMO). Seventy-three (48.7%) had WLST from ECMO support (median five days), and 33 of those (45.2%) had early WLST (≤five days). Patients who underwent WLST were older (60.3 ± 15.3 y v 49.6 ± 14.7 y; p < 0.001) than those who did not undergo WLST and had greater body mass index (31.7 ± 7.6 kg/m²v 28.3 ± 5.5 kg/m²; p = 0.002), longer ECMO duration (six v four days; p = 0.01), and higher Acute Physiology and Chronic Health Evaluation (25 v 21; p < 0.001) and Sequential Organ Failure Assessment (12 v 11; p = 0.037) scores. Family request frequently (91.7%) was cited as part of the WLST decision. WLST patients experienced more chaplaincy (89% v 65%; p < 0.001), palliative care consults (53.4% v 29.9%; p = 0.003), and code status change (do not resuscitate: 83.6% v 7.8%; p < 0.001).

Conclusions

Nearly 50% of ECMO patients underwent WLST, with approximately 25% occurring in the first 72 hours. These patients were older, sicker, and experienced a different clinical context. Unlike with other critical illnesses, neurologic injury was not a primary reason for WLST in ECMO patients.

SUBMITTER: Carlson JM

PROVIDER: S-EPMC9435591 | biostudies-literature | 2022 Mar

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation.

Carlson Julia M JM Etchill Eric W EW Enriquez Clare Angeli G CAG Peeler Anna A Whitman Glenn J GJ Choi Chun Woo CW Geocadin Romergryko G RG Cho Sung-Min SM

Journal of cardiothoracic and vascular anesthesia 20210504 3

<h4>Objective</h4>As survival with extracorporeal membrane oxygenation (ECMO) therapy improves, it is important to study patients who do not survive secondary to withdrawal of life-sustaining therapy (WLST). The purpose of the present study was to determine the population and clinical characteristics of those who experienced short latency to WLST.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Single academic hospital center.<h4>Participants</h4>Adult ECMO patients.<h4>Interventions</h ...[more]

PMID: 34088552

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Project description:BackgroundSevere COVID-19 induced acute respiratory distress syndrome (ARDS) often requires extracorporeal membrane oxygenation (ECMO). Recent German health insurance data revealed low ICU survival rates. Patient characteristics and experience of the ECMO center may determine intensive care unit (ICU) survival. The current study aimed to identify factors affecting ICU survival of COVID-19 ECMO patients.Methods673 COVID-19 ARDS ECMO patients treated in 26 centers between January 1st 2020 and March 22nd 2021 were included. Data on clinical characteristics, adjunct therapies, complications, and outcome were documented. Block wise logistic regression analysis was applied to identify variables associated with ICU-survival.ResultsMost patients were between 50 and 70 years of age. PaO2/FiO2 ratio prior to ECMO was 72 mmHg (IQR: 58-99). ICU survival was 31.4%. Survival was significantly lower during the 2nd wave of the COVID-19 pandemic. A subgroup of 284 (42%) patients fulfilling modified EOLIA criteria had a higher survival (38%) (p = 0.0014, OR 0.64 (CI 0.41-0.99)). Survival differed between low, intermediate, and high-volume centers with 20%, 30%, and 38%, respectively (p = 0.0024). Treatment in high volume centers resulted in an odds ratio of 0.55 (CI 0.28-1.02) compared to low volume centers. Additional factors associated with survival were younger age, shorter time between intubation and ECMO initiation, BMI > 35 (compared to < 25), absence of renal replacement therapy or major bleeding/thromboembolic events.ConclusionsStructural and patient-related factors, including age, comorbidities and ECMO case volume, determined the survival of COVID-19 ECMO. These factors combined with a more liberal ECMO indication during the 2nd wave may explain the reasonably overall low survival rate. Careful selection of patients and treatment in high volume ECMO centers was associated with higher odds of ICU survival.Trial registrationRegistered in the German Clinical Trials Register (study ID: DRKS00022964, retrospectively registered, September 7th 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022964 .

Project description:BackgroundSufentanil is commonly used for analgesia and sedation during extracorporeal membrane oxygenation (ECMO). Both ECMO and the pathophysiological changes derived from critical illness have significant effects on the pharmacokinetics (PK) of drugs, yet reports of ECMO and sufentanil PK are scarce. Here, we aimed to develop a population PK model of sufentanil in ECMO patients and to suggest dosing recommendations.MethodsThis prospective cohort PK study included 20 patients who received sufentanil during venoarterial ECMO (VA-ECMO). Blood samples were collected for 96 h during infusion and 72 h after cessation of sufentanil. A population PK model was developed using nonlinear mixed effects modelling. Monte Carlo simulations were performed using the final PK parameters with two typical doses.ResultsA two-compartment model best described the PK of sufentanil. In our final model, increased volume of distribution and decreased values for clearance were reported compared with previous PK data from non-ECMO patients. Covariate analysis showed that body temperature and total plasma protein level correlated positively with systemic clearance (CL) and peripheral volume of distribution (V2), respectively, and improved the model. The parameter estimates of the final model were as follows: CL = 37.8 × EXP (0.207 × (temperature - 36.9)) L h-1, central volume of distribution (V1) = 229 L, V2 = 1640 × (total plasma protein/4.5)2.46 L, and intercompartmental clearance (Q) = 41 L h-1. Based on Monte Carlo simulation results, an infusion of 17.5 μg h-1 seems to reach target sufentanil concentration (0.3-0.6 μg L-1) in most ECMO patients except hypothermic patients (33 °C). In hypothermic patients, over-sedation, which could induce respiratory depression, needs to be monitored especially when their total plasma protein level is low.ConclusionsThis is the first report on a population PK model of sufentanil in ECMO patients. Our results suggest that close monitoring of the body temperature and total plasma protein level is crucial in ECMO patients who receive sufentanil to provide effective analgesia and sedation and promote recovery.Trial registrationClinicaltrials.gov NCT02581280 , December 1st, 2014.

Dataset Information

Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation.

Objective

Design

Setting

Participants

Interventions

Measurements and main results

Conclusions

Publications

Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation.

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