The use of extracorporeal cardiopulmonary resuscitation (ECPR) to restore circulation during cardiac arrest is a time-critical, resource-intensive intervention of unproven efficacy. The current COVID-19 pandemic has brought additional complexity and significant barriers to the ongoing provision and implementation of ECPR services. The logistics of patient selection, expedient cannulation, healthcare worker safety, and post-resuscitation care must be weighed against the ethical considerations of providing an intervention of contentious benefit at a time when critical care resources are being overwhelmed by pandemic demand.

Background: A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO ₂ R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO ₂ R in supporting ultra-protective ventilation in moderate-to-severe ARDS. Methods: MEDLINE and EMBASE were interrogated for studies (2000–2021) reporting venovenous ECCO ₂ R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO ₂ R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO ₂ R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. Results: Ten studies reporting 421 patients (PaO ₂ :FiO ₂ 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH ₂ O reduction (95%-CI: 3.22–3.91) in driving pressure from baseline ( p < .001) and a 1.89 mL/kg (95%-CI: 1.75–2.02, p < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO ₂ :FiO ₂ ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. Conclusions: Venovenous ECCO ₂ R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.

The temporal trends in haematological parameters and their associations with blood product transfusion requirements in patients supported with extracorporeal membrane oxygenation (ECMO) are poorly understood. We performed a retrospective data analysis to better understand the behaviour of haematological and coagulation parameters and their associations with transfusion requirements during ECMO. Methods: Patient demographics, haematological and coagulation parameters, plasma haemoglobin and fibrinogen concentrations, platelet count, the international normalised ratio (INR), the activated partial thromboplastin time (APTT), and blood product transfusion data from 138 patients who received ECMO in a single high-volume centre were analysed. Results: Ninety-two patients received venoarterial (VA) ECMO and 46 patients received venovenous (VV) ECMO. The median (IQR) duration of VA, and VV ECMO was 8 (5–13) days and 13 (8–23) days, respectively. There were significant reductions in haemoglobin, the platelet count, and the fibrinogen concentration upon initiation of ECMO. On average, over time, patients on VV ECMO had platelet counts 44 × 10⁹/L higher than those on VA ECMO (p ≤ 0.001). Fibrinogen and APTT did not vary significantly based on the mode of ECMO (p = 0.55 and p = 0.072, respectively). A platelet count < 50 × 10⁹/L or a fibrinogen level < 1.8 g/L was associated with 50% chance of PRBC transfusion, regardless of the ECMO type, and packed red blood cell (PRBC) transfusion was more common with VA ECMO. APTT was predictive of the transfusion requirement, and the decrement in APTT was discriminatory between VVECMO survivors and nonsurvivors. Conclusion: ECMO support is associated with reductions in haemoglobin, platelet count, and fibrinogen. Patients supported with VA ECMO are more likely to receive a PRBC transfusion compared to those on VV ECMO. Thrombocytopaenia, hypofibrinogenaemia, and anticoagulation effect the likelihood of requiring PRBC transfusion. Further research is needed to define optimal blood management during ECMO, including appropriate transfusion triggers and the anticoagulation intensity.

Background: Patients with severe acute respiratory distress syndrome (ARDS) typically receive ultra-protective ventilation after extracorporeal membrane oxygenation (ECMO) is initiated. While the benefit of ECMO appears to derive from supporting “lung rest”, reductions in the intensity of mechanical ventilation, principally tidal volume limitation, may manifest radiologically. This study evaluated the relative changes in radiographic assessment of lung edema (RALE) score upon venovenous ECMO initiation in patients with severe ARDS.Methods: Digital chest x-rays (CXR) performed at baseline immediately before initiation of ECMO, and at intervals post (median 1.1, 2.1, and 9.6 days) were reviewed in 39 Adult ARDS patients. One hundred fifty-six digital images were scored by two independent, blinded radiologists according to the RALE (Radiographic Assessment of Lung Edema) scoring criteria. Ventilatory data, ECMO parameters and fluid balance were recorded at corresponding time points. Multivariable analysis was performed analyzing the change in RALE score over time relative to baseline.Results: The RALE score demonstrated excellent inter-rater agreement in this novel application in an ECMO cohort. Mean RALE scores increased from 28 (22–37) at baseline to 35 (26–42) (p < 0.001) on D1 of ECMO; increasing RALE was associated with higher baseline APACHE III scores [ß value +0.19 (0.08, 0.30) p = 0.001], and greater reductions in tidal volume [ß value −2.08 (−3.07, −1.10) p < 0.001] after ECMO initiation. Duration of mechanical ventilation, and ECMO support did not differ between survivors and non-survivors.Conclusions: The magnitude of reductions in delivered tidal volumes correlated with increasing RALE scores (radiographic worsening) in ARDS patients receiving ECMO. Implications for patient centered outcomes remain unclear. There is a need to define appropriate ventilator settings on venovenous ECMO, counterbalancing the risks vs. benefits of optimal “lung rest” against potential atelectrauma.

Superior vena cava drainage during venoarterial extracorporeal membrane oxygenation (ECMO) may reduce access insufficiency and differential oxygenation and is typically achieved via the femoral approach. Direct multistage jugular cannulation may be optimal. Despite its use at select centers, this approach is not well discussed in the literature. We present five percutaneous jugulo-femoral venoarterial ECMO initiations from our high-volume, intensivist-led service. Each case offers unique indication for direct SVC drainage in lieu of conventional femoral access. No injuries resulted from jugular cannulation, and ECMO therapy of up to 16 days proceeded in the absence of circuit or patient complications. Four patients survived to hospital discharge, while one was palliatively decannulated.

Mechanical circulatory support is increasingly utilised in peri-procedural contexts. Herein we describe the characteristics and outcomes of patients undergoing high-risk (HR) percutaneous coronary intervention (PCI) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Single centre, retrospective cohort study conducted at a quaternary Australian ECMO retrieval hospital. Consecutive patients between January 2019 and June 2024, who received peripheral VA-ECMO support for HR-PCI were identified from the institutional ECMO database. The primary outcome was the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) to hospital discharge. Secondary endpoints included procedural success, incidence of vascular access and bleeding complications, acute kidney injury (AKI), and duration of mechanical circulatory support (MCS), ventilation, ICU and hospital length of stay. Seventeen patients received VA-ECMO supported HR-PCI during the study period. The median age was 70 years (IQR; 59–78). Fourteen (82 %) patients were male; fifteen (88 %) had moderate to severe left ventricular dysfunction pre-procedurally. Ten (59 %) patients underwent emergency VA-ECMO support and seven (41 %) patients were supported prophylactically, with mean pre-procedural SYNTAX scores of 39 ± 12 and 30 ± 10, respectively. Seven MACCE events occurred, all being death in the emergency group. Fifteen patients (88 %) were successfully revascularised. Significantly more patients in the emergency versus the prophylactic group developed AKI (80 % vs 14 %, p = 0.02). There were significantly more vascular and access-related complications in the emergency group (7 vs 1, p = 0.049). In seventeen patients undergoing HR-PCI, prophylactic VA-ECMO support was feasible, safe and associated with good short-term outcomes, whilst emergency VA-ECMO supported HR-PCI was associated with greater burden of mortality and morbidity. Larger prospective studies, including cost analysis comparing other MCS devices are required.