Eleven Years of Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: From H1N1 to SARS-CoV-2. Experience and Perspectives of a National Referral Center

Objective Despite growing expertise and wide application of venovenous extracorporeal membrane oxygenation (VV ECMO) treatment for acute respiratory distress syndrome (ARDS) of different origin and during pandemics (H1N1 Influenza A virus and SARS-CoV-2), large reports are few and pertain mostly to multicenter registries, and randomized trials are difficult to perform. The aim of this study was to report outcomes, trends, and innovations of VV ECMO treatment over the last 11 years. Design, Setting, and Participants Observational study on 142 patients treated at the IRCCS San Raffaele Hospital in Milan from June 2009 (year of the H1N1 pandemic) to May 2020 (SARS-CoV-2 pandemic). Interventions None. Measurements and Main Results The main causes of ARDS were H1N1 pneumonia in 36% of patients, bacterial pneumonia in 17%, and SARS-CoV-2 in 9%. Seventy-two percent of patients were centralized from remote hospitals, of whom 33% had implanted VV ECMO before transport. The most common cannulation strategy was the dual-lumen catheter cannulation system (55%), and anticoagulation was performed with bivalirudin in most patients (79%). Refractory hypoxia was treated with intravenous beta-blockers (64%), nitric oxide (20%), and pronation (8%). Almost one-third of patients (32%) were extubated while on ECMO. Forty-nine percent of patients were discharged from the intensive care unit, and hospital discharge was 46%; survival was lower in patients requiring VV ECMO for more than three weeks compared with shorter support duration (23% v 56%, p = 0.007). Anticoagulation with bivalirudin was associated with higher survival, compared with heparin (55% v 31%, p = 0.03), and lower thrombocytopenia incidence (69% v 35%, p = 0.003). Conclusion VV ECMO is the pivotal rescue treatment for refractory ARDS—timely treatment and optimal care are needed to optimize therapy, as duration of support is associated with outcome. Anticoagulation with bivalirudin may improve outcome.

[1]  A. Zangrillo,et al.  Trend and Pattern of 100 Acute Respiratory Distress Syndrome Patients Referred for Venovenous Extracorporeal Membrane Oxygenation Treatment in a National Referral Center in North Italy During the Last Decade , 2021, Journal of cardiothoracic and vascular anesthesia.

[2]  R. Rivosecchi,et al.  Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin* , 2021, Critical care medicine.

[3]  A. Zangrillo,et al.  Venovenous ECMO treatment, outcomes, and complications in adults according to large case series: A systematic review , 2020, The International journal of artificial organs.

[4]  D. Chiumello,et al.  COVID-19 pneumonia: ARDS or not? , 2020, Critical Care.

[5]  Kiran Shekar,et al.  Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases , 2020, The Lancet Respiratory Medicine.

[6]  D. Mason,et al.  Effect of extracorporeal membrane oxygenation transport on short- and long-term survival in patients with acute respiratory distress syndrome , 2020, Proceedings.

[7]  J. Amour,et al.  Prevalence and outcome of heparin-induced thrombocytopenia diagnosed under veno-arterial extracorporeal membrane oxygenation: a retrospective nationwide study , 2018, Intensive Care Medicine.

[8]  C. Di Mario,et al.  [Tips and tricks for using extracorporeal life support devices in the intensive cardiac care unit]. , 2018, Giornale italiano di cardiologia.

[9]  D. Brodie,et al.  Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome , 2018, The New England journal of medicine.

[10]  P. Lepper,et al.  Therapeutic Interventions and Risk Factors of Bleeding During Extracorporeal Membrane Oxygenation , 2017, ASAIO journal.

[11]  B. Griffith,et al.  Bleeding, Transfusion, and Mortality on Extracorporeal Life Support: ECLS Working Group on Thrombosis and Hemostasis. , 2016, The Annals of thoracic surgery.

[12]  A. Zangrillo,et al.  Anticoagulation for critically ill cardiac surgery patients: is primary bivalirudin the next step? , 2014, Journal of cardiothoracic and vascular anesthesia.

[13]  A. Zangrillo,et al.  Primary anticoagulation with bivalirudin for patients with implantable ventricular assist devices. , 2014, Artificial organs.

[14]  M. Singer,et al.  Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. , 2013, JAMA.

[15]  M. Antonelli,et al.  A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. , 2013, Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine.

[16]  A. Zangrillo,et al.  Esmolol administration in patients with VV ECMO: why not? , 2013, Journal of cardiothoracic and vascular anesthesia.

[17]  A. Zangrillo,et al.  Cardiac support with IABP during venovenous ECMO for ARDS , 2013, Intensive Care Medicine.

[18]  A. Zangrillo,et al.  Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO , 2013, Critical Care.

[19]  A. Zangrillo,et al.  Bivalirudin versus heparin as an anticoagulant during extracorporeal membrane oxygenation: a case-control study. , 2013, Journal of cardiothoracic and vascular anesthesia.

[20]  V. Ranieri,et al.  Predicting mortality risk in patients undergoing venovenous ECMO for ARDS due to influenza A (H1N1) pneumonia: the ECMOnet score , 2012, Intensive Care Medicine.

[21]  G. Tognoni,et al.  Previous prescription of &bgr;-blockers is associated with reduced mortality among patients hospitalized in intensive care units for sepsis* , 2012, Critical care medicine.

[22]  A. Zangrillo,et al.  β-Blockers to optimize peripheral oxygenation during extracorporeal membrane oxygenation: a case series. , 2012, Journal of cardiothoracic and vascular anesthesia.

[23]  M. Antonelli,et al.  The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks , 2011, Intensive Care Medicine.

[24]  Michael Bailey,et al.  Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. , 2009, JAMA.

[25]  M. Mugford,et al.  CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure , 2006, BMC Health Services Research.

[26]  Rupert G. Miller,et al.  Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. , 1979, JAMA.