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PREDICTING SAFE LIBERATION FROM VENOVENOUS EXTRACORPOREAL LIFE SUPPORT IN PATIENTS WITH SEVERE ACUTE RESPIRATORY DISTRESS SYNDROME
CCCF Academy. Al-Fares A. 11/12/19; 283370; EP52
Dr. Abdulrahman Al-Fares
Dr. Abdulrahman Al-Fares
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ePoster
Topic: Retrospective or Prospective Cohort Study or Case Series

Al-Fares, Abdulrahman1,2,3, Fan, Eddy2,3, Ferguson, Niall2,3, Cypel, Marcelo3, Keshavjee, Shaf3, Del Sorbo, Lorenzo2,3
 
1Adult Critical Care Medicine Fellowship Program, 2Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada 3Extracorporeal Life Support Program, Toronto General Hospital, Canada
 


INTRODUCTION AND OBJECTIVE
Venovenous extracorporeal life support (VV-ECLS) for patients with severe ARDS is spreading worldwide, nonetheless, uncertainty regarding its use and management exist. Well defined criteria for both initiation and liberation are lacking. Expert opinion suggests discontinuing VV-ECLS when the patient can tolerate non-injurious mechanical ventilation (MV) settings during reduction of blood flow rate, fraction of delivered oxygen, or a sweep gas flow off trial (SGOT). We sought to describe patient conditions and MV practices at the time of VV-ECMO liberation and the potential development of respiratory and hemodynamic complications in the ensuing 48 hours.
 
METHODS
We studied adult patients receiving VV-ECLS for severe ARDS over 5 years (2012 – 2016) at the Toronto General Hospital. Failure of safe liberation from VV-ECLS was defined as development of respiratory or hemodynamic complication within 48 hours from decannulation as follows: 1) escalation of MV after decannulation (i.e., change from support modality to control modality, and/or driving pressure16 and delta driving pressure >5); 2) need for rescue therapies after decannulation (i.e., new use of neuromuscular blockers and deep sedation, and/or use of pulmonary vasodilators, and/or HFOV); or 3) new worsening hemodynamics after decannulation requiring addition of vasoactive agents. Data on patients' demographics, VV-ECLS settings and MV parameters, and outcomes are expressed as proportions or median and interquartile range (IQR), as appropriate. P values < 0.05 by chi-squared test for difference in proportions, were considered statistically significant.
 
RESULTS
A total of 55/75 patients were liberated from VV-ECLS after improvement in respiratory function. The strategy for weaning VV-ECLS was SGOT for a duration of 22 hours (15 – 25), maintaining an ECMO blood flow of 3.6 L/min (3.2 – 4.2). Baseline characteristics, MV settings during last hour of SGOT and outcomes are reported in Table 1. After VV-ECLS liberation, 14/55 (25%) patients developed respiratory or hemodynamic complications within 48 hours from decannulation. 12/14 (85%) required escalation of MV settings, 7/14 (50%) required a form of rescue therapy, and 7/14 (50%) required treatment with the new addition of vasoactive agents. In a univariate analysis, the only MV setting at the end of SGOT that is significantly associated with unsafe liberation from ECLS was tidal volume per predicted body weight (VtPBW), which was 9.2 ml/kg in patients developing complications vs 7.1 ml/kg in patients not meeting our pre-defined criteria of post decannulation complications (Table 1 and Figure 1). There was no significant difference in the VtPBW at the first hour of SGOT between the two groups. In a multivariate analysis, VtPBW and heart rate were the only two variables that were independently predictive of unsafe liberation (table 2). Although not statistically significant in our small cohort, patients developing complications had longer duration of MV, ICU and hospital length of stay.

CONCLUSIONS
In our ECLS center, a significant proportion of patients with severe ARDS liberated from VV-ECLS required an unplanned escalation of MV settings or hemodynamic support within 48 hours of decannulation. The only MV parameter during ECLS weaning that could predict safe ECLS liberation was a tidal volume per PBW. Further studies are needed to verify if these findings improve patient-centered outcomes.


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No References 

ePoster
Topic: Retrospective or Prospective Cohort Study or Case Series

Al-Fares, Abdulrahman1,2,3, Fan, Eddy2,3, Ferguson, Niall2,3, Cypel, Marcelo3, Keshavjee, Shaf3, Del Sorbo, Lorenzo2,3
 
1Adult Critical Care Medicine Fellowship Program, 2Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada 3Extracorporeal Life Support Program, Toronto General Hospital, Canada
 


INTRODUCTION AND OBJECTIVE
Venovenous extracorporeal life support (VV-ECLS) for patients with severe ARDS is spreading worldwide, nonetheless, uncertainty regarding its use and management exist. Well defined criteria for both initiation and liberation are lacking. Expert opinion suggests discontinuing VV-ECLS when the patient can tolerate non-injurious mechanical ventilation (MV) settings during reduction of blood flow rate, fraction of delivered oxygen, or a sweep gas flow off trial (SGOT). We sought to describe patient conditions and MV practices at the time of VV-ECMO liberation and the potential development of respiratory and hemodynamic complications in the ensuing 48 hours.
 
METHODS
We studied adult patients receiving VV-ECLS for severe ARDS over 5 years (2012 – 2016) at the Toronto General Hospital. Failure of safe liberation from VV-ECLS was defined as development of respiratory or hemodynamic complication within 48 hours from decannulation as follows: 1) escalation of MV after decannulation (i.e., change from support modality to control modality, and/or driving pressure16 and delta driving pressure >5); 2) need for rescue therapies after decannulation (i.e., new use of neuromuscular blockers and deep sedation, and/or use of pulmonary vasodilators, and/or HFOV); or 3) new worsening hemodynamics after decannulation requiring addition of vasoactive agents. Data on patients' demographics, VV-ECLS settings and MV parameters, and outcomes are expressed as proportions or median and interquartile range (IQR), as appropriate. P values < 0.05 by chi-squared test for difference in proportions, were considered statistically significant.
 
RESULTS
A total of 55/75 patients were liberated from VV-ECLS after improvement in respiratory function. The strategy for weaning VV-ECLS was SGOT for a duration of 22 hours (15 – 25), maintaining an ECMO blood flow of 3.6 L/min (3.2 – 4.2). Baseline characteristics, MV settings during last hour of SGOT and outcomes are reported in Table 1. After VV-ECLS liberation, 14/55 (25%) patients developed respiratory or hemodynamic complications within 48 hours from decannulation. 12/14 (85%) required escalation of MV settings, 7/14 (50%) required a form of rescue therapy, and 7/14 (50%) required treatment with the new addition of vasoactive agents. In a univariate analysis, the only MV setting at the end of SGOT that is significantly associated with unsafe liberation from ECLS was tidal volume per predicted body weight (VtPBW), which was 9.2 ml/kg in patients developing complications vs 7.1 ml/kg in patients not meeting our pre-defined criteria of post decannulation complications (Table 1 and Figure 1). There was no significant difference in the VtPBW at the first hour of SGOT between the two groups. In a multivariate analysis, VtPBW and heart rate were the only two variables that were independently predictive of unsafe liberation (table 2). Although not statistically significant in our small cohort, patients developing complications had longer duration of MV, ICU and hospital length of stay.

CONCLUSIONS
In our ECLS center, a significant proportion of patients with severe ARDS liberated from VV-ECLS required an unplanned escalation of MV settings or hemodynamic support within 48 hours of decannulation. The only MV parameter during ECLS weaning that could predict safe ECLS liberation was a tidal volume per PBW. Further studies are needed to verify if these findings improve patient-centered outcomes.


Image

No References 

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