The Korean journal of internal medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지
DOI QR코드

DOI QR Code

The effect of an improvement of experience and training in extracorporeal membrane oxygenation management on clinical outcomes

  • Kim, Go-Woon (Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Koh, Younsuck (Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Lim, Chae-Man (Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Huh, Jin Won (Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Jung, Sung Ho (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kim, Joon Bum (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Hong, Sang-Bum (Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine)
  • Received : 2015.02.03
  • Accepted : 2015.07.14
  • Published : 2018.01.01
⟨ Previous Next ⟩

Abstract

Background/Aims: The use of extracorporeal membrane oxygenation (ECMO) is spreading rapidly, with successful procedures reported in the ECMO for Severe Adult Respiratory failure (CESAR) trial and treatment of the H1N1 pandemic. However, ECMO is associated with a high mortality rate. This study aimed to show that increased experience and improved teamwork through education may reduce the mortality rate associated with ECMO. Methods: A retrospective study was performed. Data were collected from January 1, 2009, to December 31, 2011. The data were divided into two periods: 2009/2010 (period 1) and 2011 (period 2). The protocol and training program were applied during period 2. Results: Seventy-six patients were included. The most common disease requiring ECMO support was pneumonia (43.4%). ECMO was applied within 7 days in 76.3% of patients. The primary outcomes, such as Intensive Care Unit (ICU) and hospital mortality rates, were higher during period 1 (91.3%) than period 2 (66.7%, p = 0.013). A multivariate analysis revealed that ECMO weaning failure was the only factor associated with ICU and hospital mortality (ICU mortality: hazard ratio [HR], 11.349; 95% confidence interval [CI], 1.281 to 100.505; p = 0.029; hospital mortality: HR, 17.976; 95% CI, 2.263 to 142.777; p = 0.006). Conclusions: The mortality rate associated with the ECMO procedure decreased following the ECMO training program. However, applying the training program to ECMO management is not an independent factor for the mortality rate. Further studies should be performed to help reduce the mortality rate associated with ECMO.

Keywords

References

  1. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-1363. https://doi.org/10.1016/S0140-6736(09)61069-2
  2. Paden ML, Conrad SA, Rycus PT, Thiagarajan RR; ELSO Registry. Extracorporeal Life Support Organization Registry Report 2012. ASAIO J 2013;59:202-210. https://doi.org/10.1097/MAT.0b013e3182904a52
  3. Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ 2008;17 Suppl 4:S41-S47.
  4. Fleming GM, Gurney JG, Donohue JE, Remenapp RT, Annich GM. Mechanical component failures in 28,171 neonatal and pediatric extracorporeal membrane oxygenation courses from 1987 to 2006. Pediatr Crit Care Med 2009;10:439-444. https://doi.org/10.1097/PCC.0b013e318198b275
  5. Bastin AJ, Firmin R. Extracorporeal membrane oxygenation for severe acute respiratory failure in adults: NICE guidance. Heart 2011;97:1701-1703. https://doi.org/10.1136/heartjnl-2011-300708
  6. Burton KS, Pendergrass TL, Byczkowski TL, et al. Impact of simulation-based extracorporeal membrane oxygenation training in the simulation laboratory and clinical environment. Simul Healthc 2011;6:284-291. https://doi.org/10.1097/SIH.0b013e31821dfcea
  7. Anderson JM, Boyle KB, Murphy AA, Yaeger KA, LeFlore J, Halamek LP. Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations. Simul Healthc 2006;1:220-227. https://doi.org/10.1097/01.SIH.0000243550.24391.ce
  8. Extracorporeal Life Support Organization. ELSO General Guidelines [Internet]. Ann Arbor (MI): ELSO, c2016 [cited 2016 Feb 26]. Available from: http://www.elso.org/Home. aspx.
  9. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-1308. https://doi.org/10.1056/NEJM200005043421801
  10. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137:511-520. https://doi.org/10.7326/0003-4819-137-6-200209170-00012
  11. Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O'Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 2006;355:41-50. https://doi.org/10.1056/NEJMsa053993
  12. Showstack JA, Rosenfeld KE, Garnick DW, Luft HS, Schaffarzick RW, Fowles J. Association of volume with outcome of coronary artery bypass graft surgery: scheduled vs nonscheduled operations. JAMA 1987;257:785-789. https://doi.org/10.1001/jama.1987.03390060075027
  13. Lecuyer L, Chevret S, Guidet B, et al. Case volume and mortality in haematological patients with acute respiratory failure. Eur Respir J 2008;32:748-754. https://doi.org/10.1183/09031936.00142907
  14. Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999;281:1310-1317. https://doi.org/10.1001/jama.281.14.1310
  15. Young MP, Gooder VJ, Oltermann MH, Bohman CB, French TK, James BC. The impact of a multidisciplinary approach on caring for ventilator-dependent patients. Int J Qual Health Care 1998;10:15-26. https://doi.org/10.1093/intqhc/10.1.15
  16. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151-2162. https://doi.org/10.1001/jama.288.17.2151
  17. Thiara AP, Hoel TN, Kristiansen F, Karlsen HM, Fiane AE, Svennevig JL. Evaluation of oxygenators and centrifugal pumps for long-term pediatric extracorporeal membrane oxygenation. Perfusion 2007;22:323-326. https://doi.org/10.1177/0267659107086270
  18. Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011;306:1659-1668. https://doi.org/10.1001/jama.2011.1471
  19. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D, et al. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009;302:1888-1895. https://doi.org/10.1001/jama.2009.1535
  20. Kurusz M, Wheeldon DR. Risk containment during cardiopulmonary bypass. Semin Thorac Cardiovasc Surg 1990;2:400-409.
  21. Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011;365:1905-1914. https://doi.org/10.1056/NEJMct1103720
  22. Gattinoni L, Agostoni A, Pesenti A, et al. Treatment of acute respiratory failure with low-frequency positive-pressure ventilation and extracorporeal removal of $CO_2$. Lancet 1980;2:292-294.
  23. Grasselli G, Foti G, Patroniti N, et al. A case of ARDS associated with influenza A: H1N1 infection treated with extracorporeal respiratory support. Minerva Anestesiol 2009;75:741-745.
  24. Bellani G, Guerra L, Musch G, et al. Lung regional metabolic activity and gas volume changes induced by tidal ventilation in patients with acute lung injury. Am J Respir Crit Care Med 2011;183:1193-1199. https://doi.org/10.1164/rccm.201008-1318OC
  25. Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008;299:646-655. https://doi.org/10.1001/jama.299.6.646
  26. Abdelsalam M, Cheifetz IM. Goal-directed therapy for severely hypoxic patients with acute respiratory distress syndrome: permissive hypoxemia. Respir Care 2010;55:1483-1490.
  27. Terragni PP, Del Sorbo L, Mascia L, et al. Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 2009;111:826-835. https://doi.org/10.1097/ALN.0b013e3181b764d2

Cited by

  1. Reduction in ECMO mortality following increased experience: The Dubai Hospital experience vol.2017, pp.1, 2018, https://doi.org/10.5339/qmj.2017.swacelso.68
  2. Addressing the challenges of ECMO simulation vol.33, pp.7, 2018, https://doi.org/10.1177/0267659118777194
  3. Interhospital Transport on Extracorporeal Membrane Oxygenation of Neonates-Perspective for the Future vol.7, pp.None, 2018, https://doi.org/10.3389/fped.2019.00329
  4. Improvement in the survival rates of extracorporeal membrane oxygenation-supported respiratory failure patients: a multicenter retrospective study in Korean patients vol.23, pp.None, 2018, https://doi.org/10.1186/s13054-018-2293-5
  5. Mobile Extracorporeal Membrane Oxygenation vol.67, pp.5, 2018, https://doi.org/10.1097/mat.0000000000001286
  6. Analysis of the curriculum of medical humanities and social medicine in Colleges of Korean Medicine based on KAS2021 vol.42, pp.2, 2018, https://doi.org/10.13048/jkm.21017
  7. An Impact of Patient-physician Communication Curriculum on Students of Korean Medical School vol.42, pp.3, 2021, https://doi.org/10.13048/jkm.21027