Similarities in extracorporeal membrane oxygenation management across intensive care unit types in the United States: An analysis of the Extracorporeal Life Support Organization Registry
Corresponding Author
Clark G. Owyang
Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
Correspondence
Clark G. Owyang, Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 1305 York Avenue, Y-1047, Box 96, New York, NY 10021, USA.
Email: [email protected]; [email protected]
Search for more papers by this authorClaire Donnat
Department of Statistics, Stanford University, Stanford, California, USA
Search for more papers by this authorDaniel Brodie
Department of Medicine, Columbia University College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, New York, USA
Search for more papers by this authorHayley B. Gershengorn
Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
Search for more papers by this authorMay Hua
Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York, USA
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
Search for more papers by this authorNida Qadir
Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Search for more papers by this authorJoseph E. Tonna
Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
Search for more papers by this authorCorresponding Author
Clark G. Owyang
Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
Correspondence
Clark G. Owyang, Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, 1305 York Avenue, Y-1047, Box 96, New York, NY 10021, USA.
Email: [email protected]; [email protected]
Search for more papers by this authorClaire Donnat
Department of Statistics, Stanford University, Stanford, California, USA
Search for more papers by this authorDaniel Brodie
Department of Medicine, Columbia University College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, New York, USA
Search for more papers by this authorHayley B. Gershengorn
Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
Search for more papers by this authorMay Hua
Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York, USA
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
Search for more papers by this authorNida Qadir
Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Search for more papers by this authorJoseph E. Tonna
Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
Search for more papers by this authorFunding information: Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067–05, 8UL1TR000105, and UL1RR025764). Dr. Brodie receives research support from ALung Technologies. Dr. Hua is supported by a Paul B. Beeson Career Development Award (K08AG051184) from the National Institute on Aging, National Institutes of Health, and the American Federation for Aging Research. None of the funding sources were involved in the design or conduct of the study, collection, management, analysis, or interpretation of the data, or preparation, review, or approval of the manuscript
Abstract
Background
Extracorporeal membrane oxygenation (ECMO) use in the United States occurs often in cardiothoracic ICUs (CTICU). It is unknown how it varies across ICU types.
Methods
We identified 10 893 ECMO runs from the Extracorporeal Life Support Organization (ELSO) Registry across 2018 and 2019. Primary outcome was ECMO case volume by ICU type (CTICU vs. non-CTICU). Adjusting for pre-ECMO characteristics and case mix, secondary outcomes were on-ECMO physiologic variables by ICU location stratified by support type.
Results
CTICU ECMO occurred in 65.1% and 55.1% (2018 and 2019) of total runs. A minority of total runs related to cardiac surgery procedures (CTICU: 21.7% [2018], 18% [2019]; non-CTICU: 11.2% [2018], 13% [2019]). After multivariate adjustment, non-CTICU ECMO for cardiac support associated with lower 4- and 24-h circuit flow (3.9 liters per minute [LPM] vs. 4.1 LPM, p < 0.0001; 4.1 LPM vs. 4.3 LPM, p < 0.0001); for respiratory support, lower on-ECMO mean fraction of inspired oxygen ([FiO2], 67% vs. 69%, p = 0.02) and lower respiratory rate (14 vs. 15, p < 0.0001); and, for extracorporeal cardiopulmonary resuscitation (ECPR), lower ECMO flow rates at 24 h (3.5 LPM vs. 3.7 LPM, p = 0.01).
Conclusions
ECMO mostly remains in CTICUs though a minority is associated with cardiac surgery. Statistically significant but clinically minor differences in on-ECMO metrics were observed across ICU types.
CONFLICT OF INTEREST
No conflicts of interest to declare.
Open Research
DATA AVAILABILITY STATEMENT
Our analytic code is available in the Open Science Foundation repository (DOI:10.17605/OSF.IO/5WN6G, available at https://osf.io/5wn6g/) to facilitate research reproducibility, replicability, accuracy, and transparency. Code was deidentified in accordance with section 164.514 of the Health Insurance Portability and Accountability Act. Data that support the findings of this work are available from ELSO and were used under license for the current study. The data can be requested from ELSO.
Supporting Information
| Filename | Description |
|---|---|
| aor14193-sup-0001-supinfo.docxWord 2007 document , 913.6 KB |
Appendix S1 |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use has increased by 433% in adults in the United States from 2006 to 2011. ASAIO J. 2015; 61(1): 31–6.
- 2Zakhary B, Oppenheimer BW. ECMO for all? Challenging traditional ECMO contraindications. J Crit Care. 2018; 48: 451–2.
- 3Park TK, Yang JH, Jeon K, Choi SH, Choi JH, Gwon HC, et al. Extracorporeal membrane oxygenation for refractory septic shock in adults. Eur J Cardiothorac Surg. 2015; 47(2): e68–74.
- 4Loughran J, Puthawala T, Sutton BS, Brown LE, Pronovost PJ, DeFilippis AP. The cardiovascular intensive care unit-an evolving model for health care delivery. J Intensive Care Med. 2017; 32(2): 116–23.
- 5Guihaire J, Owyang CG, Madhok J, Laverdure F, Gaillard M, Girault A, et al. Specific considerations for venovenous-extracorporeal membrane oxygenation during Coronavirus Disease-2019 pandemic. ASAIO J. 2020; 66: 1069–72.
- 6Worku E, Gill D, Brodie D, Lorusso R, Combes A, Shekar K. Provision of ECPR during COVID-19: evidence, equity, and ethical dilemmas. Critical Care. 2020; 24(1): 462.
- 7Harvey MJ, Gaies MG, Prosser LA. U.S. and international in-hospital costs of extracorporeal membrane oxygenation: a systematic review. Appl Health Econ Health Policy. 2015; 13(4): 341–57.
- 8Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, et al. Extracorporeal life support in hemorrhagic conditions: a systematic review. ASAIO J. 2020; 67: 476–84.
- 9Acharya D, Torabi M, Borgstrom M, Rajapreyar I, Lee K, Kern K, et al. Extracorporeal membrane oxygenation in myocardial infarction complicated by cardiogenic shock: analysis of the ELSO Registry. J Am Coll Cardiol. 2020; 76(8): 1001–2.
- 10Brechot N, Hajage D, Kimmoun A, Demiselle J, Agerstrand C, Montero S, et al. Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study. Lancet. 2020; 396(10250): 545–52.
- 11Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA. 2019; 322(6): 557–68.
- 12Trivedi JR, Alotaibi A, Sweeney JC, Fox MP, van Berkel V, Adkins K, et al. Use of extracorporeal membrane oxygenation in blunt traumatic injury patients with acute respiratory distress syndrome. ASAIO J. 2021; 34352816. Publish Ahead of Print.
- 13Ling RR, Ramanathan K, Poon WH, Tan CS, Brechot N, Brodie D, et al. Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis. Crit Care. 2021; 25(1): 246.
- 14Bartlett RH. Extracorporeal life support: history and new directions. ASAIO J. 2005; 51(5): 487–9.
- 15Combes A, Hajage D, Capellier G, Demoule A, Lavoue S, Guervilly C, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018; 378(21): 1965–75.
- 16Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009; 374(9698): 1351–63.
- 17Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, et al. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg. 2017; 12(1): 55.
- 18Capoccia M, Maybauer MO. Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review. World J Crit Care Med. 2019; 8(8): 135–47.
- 19Menaker J, Dolly K, Rector R, Kufera J, Lee EE, Tabatabai A, et al. The lung rescue unit-Does a dedicated intensive care unit for venovenous extracorporeal membrane oxygenation improve survival to discharge? J Trauma Acute Care Surg. 2017; 83(3): 438–42.
- 20Biscotti M, Gannon WD, Agerstrand C, Abrams D, Sonett J, Brodie D, et al. Awake extracorporeal membrane oxygenation as bridge to lung transplantation: a 9-year experience. Ann Thorac Surg. 2017; 104(2): 412–9.
- 21Merkle J, Djorjevic I, Sabashnikov A, Kuhn EW, Deppe AC, Eghbalzadeh K, et al. Mobile ECMO—a divine technology or bridge to nowhere? Expert Rev Med Devices. 2017; 14(10): 821–31.
- 22Taleb I, Koliopoulou AG, Tandar A, McKellar SH, Tonna JE, Nativi-Nicolau J, et al. Shock team approach in refractory cardiogenic shock requiring short-term mechanical circulatory support: a proof of concept. Circulation. 2019; 140(1): 98–100.
- 23Haas NL, Coute RA, Hsu CH, Cranford JA, Neumar RW. Descriptive analysis of extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest-An ELSO registry study. Resuscitation. 2017; 119: 56–62.
- 24Karagiannidis C, Brodie D, Strassmann S, Stoelben E, Philipp A, Bein T, et al. Extracorporeal membrane oxygenation: evolving epidemiology and mortality. Intensive Care Med. 2016; 42(5): 889–96.
- 25Raffa GM, Kowalewski M, Brodie D, Ogino M, Whitman G, Meani P, et al. Meta-Analysis of Peripheral or Central Extracorporeal Membrane Oxygenation in Postcardiotomy and Non-Postcardiotomy Shock. Ann Thorac Surg. 2019; 107(1): 311–21.
- 26Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB, et al. Patient and institutional characteristics influence the decision to use extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest. J Am Heart Assoc. 2020; 9: e015522.
- 27Goh KJ, Tan QL, Tay CK, Sewa DW, Lee KCH, Phua GC. Impact of an extracorporeal membrane oxygenation intensivist-led multidisciplinary team on venovenous extracorporeal membrane oxygenation outcomes. Crit Care Explor. 2020; 2(12):e0297.
- 28DellaVolpe J, Barbaro RP, Cannon JW, Fan E, Greene WR, Gunnerson KJ, et al. Joint society of critical care medicine-extracorporeal life support organization task force position paper on the role of the intensivist in the initiation and management of extracorporeal membrane oxygenation. Crit Care Med. 2020; 48: 838–46.
- 29Rabie AA, Azzam MH, Al-Fares AA, Abdelbary A, Mufti HN, Hassan IF, et al. Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India. Intensive Care Med. 2021; 47(8): 887–95.
- 30Hackmann AE, Wiggins LM, Grimes GP, Fogel RM, Schenkel FA, Barr ML, et al. The utility of nurse-managed extracorporeal life support in an adult cardiac intensive care unit. Ann Thorac Surg. 2017; 104(2): 510–4.
- 31Kowalewski M, Raffa GM, Zielinski K, Alanazi M, Gilbers M, Heuts S, et al. The impact of Centre’s heart transplant status and volume on in-hospital outcomes following extracorporeal membrane oxygenation for refractory post-cardiotomy cardiogenic shock: a meta-analysis. BMC Cardiovasc Disord. 2020; 20(1): 10.
- 32Kowalewski M, Zielinski K, Gozdek M, Raffa GM, Pilato M, Alanazi M, et al. Veno-arterial extracorporeal life support in heart transplant and ventricle assist device centres. meta-analysis. ESC Heart Fail; 2020; 33337072.
- 33Barbaro RP, Odetola FO, Kidwell KM, Paden ML, Bartlett RH, Davis MM, et al. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the Extracorporeal Life Support Organization Registry. American Journal of Respiratory and Critical Care Medicine. 2015; 191(8): 894–901.
- 34Kerlin MP, Epstein A, Kahn JM, Iwashyna TJ, Asch DA, Harhay MO, et al. Physician-level variation in outcomes of mechanically ventilated patients. Ann Am Thorac Soc. 2018; 15(3): 371–9.
- 35Gershengorn HB. Is My Intensivist Better Than Your Intensivist? Ann Am Thorac Soc. 2018; 15(3): 312–4.
- 36Gershengorn HB, Harrison DA, Garland A, Wilcox ME, Rowan KM, Wunsch H. Association of Intensive Care Unit Patient-to-Intensivist Ratios With Hospital Mortality. JAMA Intern Med. 2017; 177(3): 388–96.
- 37Briggs S, Ambler J, Smith D. A survey of tracheostomy practice in a cardiothoracic intensive care unit. J Cardiothorac Vasc Anesth. 2007; 21(1): 76–80.
- 38Jabaley CS, Groff RF, Sharifpour M, Raikhelkar JK, Blum JM. Modes of mechanical ventilation vary between hospitals and intensive care units within a university healthcare system: a retrospective observational study. BMC Res Notes. 2018; 11(1): 425.
- 39Whitman GJ. Extracorporeal membrane oxygenation for the treatment of postcardiotomy shock. J Thorac Cardiovasc Surg. 2017; 153(1): 95–101.
- 40von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007; 335(7624): 806–8.
- 41Nasr VG, Raman L, Barbaro RP, Guner Y, Tonna J, Ramanathan K, et al. Highlights from the Extracorporeal Life Support Organization Registry: 2006–2017. ASAIO J. 2019; 65(6): 537–44.
- 42Barbaro RP, MacLaren G, Boonstra PS, Iwashyna TJ, Slutsky AS, Fan E, et al. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet. 2020; 396(10257): 1071–8.
- 43 ELSO. Data definitions, forms, instructions ELSO.org. Available from: https://www.elso.org/Registry/DataDefinitions,Forms,Instructions.aspx.
- 44Fraser CD Jr, Jaquiss RD, Rosenthal DN, Humpl T, Canter CE, Blackstone EH, et al. Prospective trial of a pediatric ventricular assist device. N Engl J Med. 2012; 367(6): 532–41.
- 45Thiagarajan RR, Barbaro RP, Rycus PT, McMullan DM, Conrad SA, Fortenberry JD, et al. Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J. 2017; 63(1): 60–7.
- 46Dalton HJ, Butt WW. Extracorporeal life support: an update of Rogers' Textbook of Pediatric Intensive Care. Pediatr Crit Care Med. 2012; 13(4): 461–71.
- 47Lorusso R, Alexander P, Rycus P, Barbaro R. The Extracorporeal Life Support Organization Registry: update and perspectives. Ann Cardiothorac Surg. 2019; 8(1): 93–8.
- 48Schmidt M, Bailey M, Sheldrake J, Hodgson C, Aubron C, Rycus PT, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med. 2014; 189(11): 1374–82.
- 49Zabrocki LA, Brogan TV, Statler KD, Poss WB, Rollins MD, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory failure: survival and predictors of mortality. Crit Care Med. 2011; 39(2): 364–70.
- 50Schmidt M, Burrell A, Roberts L, Bailey M, Sheldrake J, Rycus PT, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. European Heart Journal. 2015; 36(33): 2246–56.
- 51Kim SJ, Han KS, Lee EJ, Lee SJ, Lee JS, Lee SW. Association between Extracorporeal Membrane Oxygenation (ECMO) and mortality in the patients with cardiac arrest: a nation-wide population-based study with propensity score matched analysis. J Clin Med. 2020; 9(11): 3703.
- 52Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40(5): 373–83.
- 53van van Buuren S, Groothuis-Oudshoorn K. Mice: multivariate imputation by chained equations in R. J Stat Softw. 2011. 45 (3): 1–67.
- 54Wohlfarth P, Beutel G, Lebiedz P, Stemmler HJ, Staudinger T, Schmidt M, et al. Characteristics and outcome of patients after allogeneic hematopoietic stem cell transplantation treated with extracorporeal membrane oxygenation for acute respiratory distress syndrome. Crit Care Med. 2017; 45(5): e500–e7.
- 55Kagawa E, Dote K, Kato M, Sasaki S, Nakano Y, Kajikawa M, et al. Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation. 2012; 126(13): 1605–13.
- 56Russo JJ, Aleksova N, Pitcher I, Couture E, Parlow S, Faraz M, et al. Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock. J Am Coll Cardiol. 2019; 73(6): 654–62.
- 57Yannopoulos D, Bartos JA, Raveendran G, Conterato M, Frascone RJ, Trembley A, et al. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. J Am Coll Cardiol. 2017; 70(9): 1109–17.
- 58Wood DE. Cardiothoracic surgery: a specialty divided or as one. J Thorac Cardiovasc Surg. 2009; 137(1): 1–9.
- 59Hryniewicz K, Hart M, Raile D, Wang Y, Mooney M, Mudy K, et al. Multidisciplinary shock team is associated with improved outcomes in patients undergoing ECPR. Int J Artif Organs. 2021; 44: 310–7.
- 60Hong D, Choi KH, Cho YH, Cho SH, Park SJ, Kim D, et al. Multidisciplinary team approach in acute myocardial infarction patients undergoing veno-arterial extracorporeal membrane oxygenation. Ann Intensive Care. 2020; 10(1): 83.
- 61Nagaoka E, Arai H, Ugawa T, Masuda T, Ochiai K, Tamaoka M, et al. Efficacy of multidisciplinary team approach with extracorporeal membrane oxygenation for COVID-19 in a low volume ECMO center. Artif Organs. 2021; 45(9): 1061–7.
- 62Shekar K, Badulak J, Peek G, Boeken U, Dalton HJ, Arora L, et al. Extracorporeal Life Support Organization COVID-19 Interim Guidelines. ASAIO J. 2020; 66(7): 707–21.
Citing Literature
