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      Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation

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          Abstract

          Background

          Bleeding is the most frequent complication associated with extracorporeal membrane oxygenation (ECMO) support in critically ill patients. Nonetheless, risk factors for bleeding have been poorly described especially those associated with coagulation anomalies and anticoagulant therapy during ECMO support. The aim of this study is to describe bleeding complications in critically ill patients undergoing ECMO and to identify risk factors for bleeding events.

          Methods

          We retrospectively analysed ICU charts of adults who received either veno-venous (VV) or veno-arterial (VA) ECMO support in two participating ICUs between 2010 and 2013. Characteristics of patients with and without bleeding complications, as per the Extracorporeal Life Support Organisation (ELSO) definition, were compared, and the impact of bleeding complications on patient outcomes was assessed using survival analysis. Variables that were independently associated with bleeding, including daily clinical and biological variables during ECMO courses, were modelled.

          Results

          Of the 149 ECMO episodes (111 VA ECMO and 38 VV ECMO) performed in 147 adults, 89 episodes (60 %) were complicated by at least one bleeding event. The most common bleeding sources were: ECMO cannula (37 %), haemothorax or cardiac tamponade (17 %) and ear–nose and throat (16 %). Intra-cranial haemorrhage occurred in five (2.2 %) patients. Bleeding complications were independently associated with worse survival [adjusted hazard ratio (HR) 2.17, 95 % confidence interval (CI) 1.07–4.41, P = 0.03]. Higher activated partial thromboplastin time (aPTT) [adjusted odds ratio (OR) 3.00, 95 % CI 1.64–5.47, P < 0.01], APACHE III score [adjusted OR 1.01, 95 % CI 1.01–1.02, P = 0.01] and ECMO following surgery [adjusted OR 3.04, 95 % CI 1.62–5.69, P < 0.01] were independently associated with greater risk of bleeding occurrence. A similar association between bleeding and higher aPTT was found when non-post-surgical VA ECMO was considered separately.

          Conclusions

          Bleeding events based on the ELSO bleeding definition occurred in more than 60 % of ECMO episodes and were associated with hospital mortality. We identified higher aPTT prior bleeding as an independent risk factor for bleeding event, suggesting that better control of the aPTT (through a better control of either coagulopathy or anticoagulation) may improve patients’ outcome.

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          Most cited references19

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          Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome.

          The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO). To describe the characteristics of all patients with 2009 influenza A(H1N1)-associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes. An observational study of all patients (n = 68) with 2009 influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009. Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival. Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) Pao(2)/fraction of inspired oxygen (Fio(2)) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H(2)O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO. During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)-associated respiratory failure, one-third of whom received ECMO. These ECMO-treated patients were often young adults with severe hypoxemia and had a 21% mortality rate at the end of the study period.
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            Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock.

            To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock. Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g., ECMO. ECMO-associated morbidity and mortality plead for identification of early predictors of its failure, and detailed analyses of short- and long-term outcomes to refine patient selection and improve results. Outcomes of 81 patients given ECMO support for medical (n = 55), postcardiotomy (n = 16), or posttransplantation (n = 10) cardiogenic shock were evaluated. Thirty-four (42%) patients survived to hospital discharge; 57% suffered > or = 1 major ECMO-related complications. Independent predictors of intensive care unit death were: device insertion under cardiac massage (odds ratio [OR] = 20.68), 24 hr urine output < 500 mL (OR = 6.52), prothrombin activity < 50% (OR = 3.93), and female sex (OR = 3.89); myocarditides were associated with better outcomes (OR = .13). Sequelae and health-related quality-of-life were evaluated for 28 long-term survivors (median follow-up, 11 months), whose mean Short-Form 36 scores were significantly lower than matched healthy controls for physical role, general health, and social functioning, but higher than those reported for patients on chronic hemodialysis, with advanced heart failure, or after recovery from acute respiratory distress syndrome. ECMO support can rescue 40% of otherwise fatal cardiogenic shock patients but its initiation under cardiac massage or after renal or hepatic failure carried higher risks of intensive care unit death, while fulminant myocarditis had a better prognosis. Despite satisfactory mental health and vitality, long-term survivors' persistent physical and social problems might benefit from tailored medical or psychosocial interventions.
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              Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database.

              To evaluate clinical and treatment factors for patients recorded in the Extracorporeal Life Support Organization (ELSO) registry and survival of adult extracorporeal membrane oxygenation (ECMO) respiratory failure patients. Retrospective case review of the ELSO registry from 1986-2006. Data were analyzed separately for the entire time period and the most recent years (2002-2006). Of 1,473 patients, 50% survived to discharge. Median age was 34 years. Most patients (78%) were supported with venovenous ECMO. In a multi-variate logistic regression model, pre-ECMO factors including increasing age, decreased weight, days on mechanical ventilation before ECMO, arterial blood pH or= 70 compared to PaCO(2) 7.6 were associated with increased odds of death. Survival among this cohort of adults with severe respiratory failure supported with ECMO was 50%. Advanced patient age, increased pre-ECMO ventilation duration, diagnosis category and complications while on ECMO were associated with mortality. Prospective studies are needed to evaluate the role of this complex support mode.
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                Author and article information

                Contributors
                +61 2 98 34 71 81 , Cecile.aubron@chu-brest.fr , cecile.aubron@monash.edu
                jorisdepuydt@telenet.be
                fbelon@chu-besancon.fr
                michael.bailey@monash.edu
                matthieuschmidt@yahoo.fr
                Ja.Sheldrake@alfred.org.au
                deirdre8murphy@gmail.com
                cd@scheinkestel.com.au
                jamie.cooper@monash.edu
                gilles.capellier@univ-fcomte.fr
                V.Pellegrino@alfred.org.au
                D.Pilcher@alfred.org.au
                zoe.mcquilten@monash.edu
                Journal
                Ann Intensive Care
                Ann Intensive Care
                Annals of Intensive Care
                Springer Paris (Paris )
                2110-5820
                6 October 2016
                6 October 2016
                2016
                : 6
                : 97
                Affiliations
                [1 ]The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
                [2 ]The Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
                [3 ]The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
                [4 ]University Hospital of Antwerp, 2000 Antwerp, Belgium
                [5 ]The Intensive Care Unit, Jean Minjoz Hospital, 25030 Besançon, France
                [6 ]School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
                [7 ]Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609 Brest Cedex, France
                [8 ]LUBEM, EA 3882 - Université de Bretagne Occidentale, 29 200 Brest, France
                [9 ]Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié–Salpetrière, Assistance Publique–Hôpitaux de Paris, Paris, France
                Article
                196
                10.1186/s13613-016-0196-7
                5053950
                27714705
                a3d11c20-ba8f-4b73-b049-a0897ae49e0c
                © The Author(s) 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 21 July 2016
                : 18 September 2016
                Categories
                Research
                Custom metadata
                © The Author(s) 2016

                Emergency medicine & Trauma
                extra corporeal membrane oxygenation,critically ill patients,haemorrhage,bleeding,anticoagulation,coagulopathy,thromboembolic events

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