Early venoarterial extracorporeal membrane oxygenation improves outcomes in post-cardiotomy shock
- PDF / 1,953,654 Bytes
- 8 Pages / 595.276 x 790.866 pts Page_size
- 76 Downloads / 185 Views
ORIGINAL ARTICLE Artificial Heart (Clinical)
Early venoarterial extracorporeal membrane oxygenation improves outcomes in post‑cardiotomy shock Amit Saha1 · Paul Kurlansky1 · Yuming Ning2 · Joseph Sanchez1 · Justin Fried3 · Lucas J. Witer1 · Yuji Kaku1 · Hiroo Takayama1 · Yoshifumi Naka1 · Koji Takeda1 Received: 27 June 2020 / Accepted: 2 September 2020 © The Japanese Society for Artificial Organs 2020
Abstract Post-cardiotomy shock (PCS) is associated with substantial morbidity and mortality. We reviewed our 12-year experience of venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy for PCS. Between July 2007 and June 2018, 156 consecutive patients underwent VA-ECMO for PCS. We retrospectively investigated patient characteristics, indications, and management to determine factors affecting outcomes. Secondary analysis was performed by dividing the cohort into Era 1 (2007–2012, n = 52) and Era 2 (2013–2018, n = 104) for comparison. After a median of 4.70 days (interquartile range [IQR] 2.76–8.53) of ECMO support, 72 patients (46.1%) survived to discharge. In-hospital mortality decreased in Era 2 from 75 to 43.3% (P 10 mcg/min, epinephrine > 4 mcg/min, or dobutamine > 5 mcg/kg/min is considered high-dose support. Femoral access has become our preferred strategy to allow for early chest closure, to more readily permit extubation, and to facilitate decannulation without chest reopening. Central cannulation is also associated with increased morbidity and mortality [19]. Central cannulation is selected if patients develop severe hypoxia due to acute lung injury, require open chest due to significant bleeding, have severe peripheral vasculopathy, or require significant hemodynamic support that would not be possible with a partial flow strategy. We have adopted a partial flow strategy to facilitate aortic valve opening, particularly to prevent prosthetic valve thrombosis [20, 21]. We aim to maintain flow rates of 60–80% of total cardiac output. Pulmonary artery catheter is routinely placed and flow is adjusted in conjunction with inotropes and inhaled nitrous oxide to maintain ejection through the aortic and pulmonary valves. Surgical left ventricular vent is added if patients develop left ventricular distension or
13
Journal of Artificial Organs
lose arterial pulsatility. Intra-aortic balloon pump is typically utilized in patients with prosthetic aortic valves or whose arterial pulse pressure decreases below 10 mmHg. Inotropic support is used to augment native cardiac output. In the early study period, limb ischemia was monitored by clinical signs and Doppler signals in the dorsalis pedis and posterior tibial arteries. Since 2017, we have used nearinfrared reflectance spectroscopy attached distally to detect limb ischemia. When distal limb saturation falls below 60%, an 8 Fr distal perfusion cannula is inserted into the superficial femoral artery [22]. Protamine is administered to reverse heparin in the operating room. Once the chest is closed and chest tube drainage becomes serous, anticoagulation wit
Data Loading...
