Mücahit AVCİL, Duygu EGE, Yunus Emre ÖZLÜER, Kezban ŞEKER YAŞAR

Emergency department extracorporeal membrane oxygenation may also include noncardiac arrest patients

Background/aim: The primary purpose of this study is to report the experience on the extracorporeal membrane oxygenation (ECMO) process for patients in the critical care unit (CCU) of an emergency department of a tertiary hospital in Turkey, from cannulation to decannulation, including follow-up procedures. Materials and methods: This retrospective and observational study included eight patients who received ECMO from January 2018 to January 2020. We evaluated the demographics, indications for ECMO, laboratory values, Respiratory ECMO Survival Prediction, Survival After Veno-Arterial ECMO and ECMO net scores, the management process, and patient outcomes. Blood gas analyses done after the first hour of ECMO initiation and the reevaluation of the patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores in the 24th hour of ECMO were recorded. Results: The mean age was 52.7 ± 14.2 years. The median duration of the ECMO run was 81 (min–max: 4–267) h, and the mean length of CCU stay was 10.2 ± 6.7 days. Of the 8 patients studied, 5 (62.5%) had veno-arterial and 3 (37.5%) had veno-venous ECMO. Three patients were successfully weaned (37.5%). The overall survival-to-discharge rate was 25%. Carbon dioxide levels were significantly decreased 1 h after ECMO initiation (P = 0.038) as well as the need for vasopressors. Lactate levels were lower in decannulated patients. Changes in the APACHE II score were more consistent with the clinical deterioration in patients than SOFA score changes were. Conclusions: In the early phase of ECMO, vital signs improve, and the need for vasopressors and carbon dioxide levels decrease. Thus, CCUs in Emergency Departments with ECMO capabilities could potentially be designed, and emergency department ECMO algorithms could be tailored for critically ill patients in addition to out-of-hospital cardiac arrest patients.Key words: Extracorporeal membrane oxygenation, emergency department, cardiac arrest, resuscitation, critical care

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1. Napp LC, Kühn C, Bauersachs J. ECMO in cardiac arrest and cardiogenic shock. Herz 2017; 42: 27-44. doi: 10.1007/s00059- 016-4523-4
2. Bartlett RH. Esperanza: presidential address. Transactions of American Society for Artificial Internal Organs 1985; 31: 723- 726.
3. Sun T, Guy A, Sidhu A, Finlayson G, Grunau B et al. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support. Journal of Critical Care 2018; 44: 31-38. doi: 10.1016/j.jcrc.2017.10.011
4. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D, Bailey M, Beca J, Bellomo R, et al. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. Journal of the American Medical Association 2009; 302: 1888-1895. doi: 10.1001/ jama.2009.1535
5. American Heart Association. American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132: 316- 589. doi: 10.1161/CIR.0000000000000262
6. Shinar Z, Plantmason L, Reynolds J, Dembitsky W, Bellezzo J et al. Emergency physician-initiated resuscitative extracorporeal membrane oxygenation. Journal of Emergency Medicine 2019; 56(6): 666-673. doi: 10.1016/j.jemermed.2019.02.004
7. Extracorporeal Life Support Organization. Guidelines for Cardiopulmonary Extracorporeal Support. Ann Arbor, MI, USA: ELSO; 2017.
8. Weiner L, Mazzeffi MA, Hines EQ, Gordon D, Herr DL et al. Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations’ ECMO case registry. Clinical Toxicology 2019; 16: 1-6. doi: 10.1080/15563650.2019.1676896
9. Kraut JA, Madias NE. Lactic acidosis. New England Journal of Medicine 2014; 371: 2309-2319. doi: 10.1056/NEJMra1309483
10. Huang L, Li T, Xu L, Hu XM, Duan SW et al. Performance of multiple risk assessment tools to predict mortality for adult respiratory distress syndrome with extracorporeal membrane oxygenation therapy: An external validation study based on Chinese single-center data. Chinese Medical Journal 2016; 129: 1688-1695. doi: 10.4103/0366-6999.185871
11. Naqvi IH, Mahmood K, Ziaullaha S, Kashif SM, Sharif A. Better prognostic marker in ICU - APACHE II, SOFA or SAP II!. Pakistan Journal of Medical Sciences 2016; 32: 1146-1151. doi: 10.12669/pjms.325.10080
12. Kim SJ, Kim HJ, Lee HY, Ahn HS, Lee SW. Comparing extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: A metaanalysis. Resuscitation 2016; 103: 106-116. doi: 10.1016/j. resuscitation.2016.01.019
13. Wengenmayer T, Rombach S, Ramshorn F, Biever P, Bode C et al. Influence of low-flow time on survival after extracorporeal cardiopulmonary resuscitation (eCPR). Critical Care 2017; 21: 157-162. doi: 10.1186/s13054-017-1744-8
14. Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL et al. Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Critical Care Medicine 2008; 36: 1404- 1411. doi: 10.1097/CCM.0b013e31816f7cf7
15. Steimer DA, Hernandez O, Mason DP, Schwartz GS. Timing of ECMO initiation impacts survival in influenza-associated ARDS. The Journal of Thoracic and Cardiovascular Surgery 2019; 67: 212-215. doi: 10.1055/s-0038-1642066
16. Bellezzo JM, Shinar Z, Davis DP, Jaski BE, Chillcott S et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitation. Resuscitation 2012; 83 (8): 966-970. doi: 10.1016/j.resuscitation.2012.01.027
17. Swol J, Belohlávek J, Brodie D, Bellezzo J, Weingart SD et al. Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation 2018; 133: 108-117. doi: 10.1016/j.resuscitation.2018.10.014
18. Tonna JE, Selzman CH, Mallin MP, Smith BR, Youngquist ST et al. Development and implementation of a comprehensive, multidisciplinary emergency department extracorporeal membrane oxygenation program. Annals of Emergency Medicine 2017; 70: 32-40. doi: 10.1016/j. annemergmed.2016.10.001