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ПЕРИОПЕРАЦИОННЫЕ ТЕХНОЛОГИИ
ПРОГРАММА ЭКСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИЙ В КАЗАХСТАНЕ: БЛИЖАЙШИЕ РЕЗУЛЬТАТЫ
Пя Ю.В., Калиев Р.Б., Лесбеков Т.Д., Бекбосынов С.Т., Капышев Т.С., Нурмыхаметова Ж.А., Смагулов Н.К., Аширов Ж.З., Фаизов Л.Р.
Национальный научный кардиохирургический центр, Астана, Республика Казахстан
Экстракорпоральная мембранная оксигенация, международный консорциум (ЭКМО) - процедура продленного искусственного кровообращения и насыщения крови кислородом (оксигенация) вне организма, используемая у пациентов с остро развившейся и потенциально обратимой дыхательной и/или сердечной недостаточностью, лечение которых не поддается максимальной стандартной терапии. Организация экстракорпорального жизнеобеспечения (Е1_Б0) является международным консорциумом центров здравоохранения, который разрабатывает, оценивает и усовершенствует использование ЭКМО. В 2011 г. в нашем центре начала работу программа по обеспечению ЭКМО в Казахстане, а в 2013 г. он вошел в регистр Е1_Б0. В данной статье описывается первый опыт и госпитальные результаты клинического применения ЭКМО в нашем центре.
Клин. и эксперимент. хир. Журн. им. акад. Б.В. Петровского. 2017. № 1. С. 41-44.
Статья поступила в редакцию: 15.01.2017. Принята в печать: 01.02.2017.
ДЛЯ КОРРЕСПОНДЕНЦИИ
Нурмыхаметова Жулдыз Аскаровна - врач-перфузиолог операционного отделения с лабораторией вспомогательного кровообращения Национального научного кардиохирургического центра (Астана, Республика Казахстан)
E-mail: Hzhyziknurik@icloud.com
Ключевые слова:
экстракорпоральная мембранная оксигенация, международный консорциум
Extracorporeal Membrane Oxygenation program in Kazakhstan: early outcomes
Pya Yu., Kaliyev R., Lesbekov T., Bekbossynov S., Kapyshev T., Nurmykhametova Zh., Smagulov N., Ashyrov Zh., Faizov L.
National Research Cardiac Surgery Center, Astana, Republic of Kazakhstan
Extracorporeal membrane oxygenation (ECMO) is an established rescue therapy for severe respiratory failure, cardiogenic shock, and cardiac arrest refractory to conventional therapeutic modalities including ventilatory and high-dose inotropic support. The Extracorporeal Life Support Organization (ELSO) is an international consortium of health care institutions that maintains a registry of ECMO use. In 2011, we initiated the first ECMO program in Kazakhstan, and since 2013 our Center is a member of ELSO. This paper describes the initial experience and early outcomes of ECMO in our Center.
CORRESPONDENCE
Nurmykhametova Zhuldyz -Perfusiologist, Operating Room with a Laboratory of Andllary Circulation, National Research Cardiac Surgery Center (Astana, Republic of Kazakhstan) E-mail: Hzhyziknurik@icloud.com
Keywords:
extracorporeal membrane oxygenation, international consortium
Clin. Experiment. Surg. Petrovsky J. 2017; 5 (1): 41-44.
Received: 15.01.2017. Accepted: 01.02.2017.
Introduction
Extracorporeal membrane oxygenation is an established rescue therapy for severe respiratory failure, cardiogenic shock, and cardiac arrest refractory to conventional therapeutic modalities including ventilatory and high-dose inotropic support [1]. Extracorporeal membrane oxygenation (ECMO) provides days to month of support for patients with respiratory, cardiac, or combined cardiopulmonary failure. For patients with isolated respiratory failure, venove-nous (VV) ECMO is typically employed to provide sup-
port while the lungs recover. Venoarterial (VA) ECMO is available for cases of cardiac or cardiopulmonary failure. The Extracorporeal Life Support Organization is an international consortium of health care institutions that maintains a registry of ECMO use. As of July 2016, the Extracorporeal Life Support Organization has captured more than 78,000 ECMO implementations, with more than 22,000 in adult patients (Table 1) [2].
Over the last few years, the use of ECMO continues to be an important issue for clinicians, also
Table 1. Outcomes of all extracorporeal membrane oxygenation cases recorded by the Extracorporeal Life Support Organization (ELSO) from 1985 through 2016, organized by cardiac, respiratory, and cardiopulmonary resuscitation (E-CPR) indications. (ECMO) Extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation
Overall Outcomes
Total Patients Survived ECLS Survived to DC or Transfer
Neonatal
Respiratory 29,153 24,488 84% 21,545 74%
Cardiac 6,475 4,028 62% 2,695 42%
ECPR 1,336 859 64% 547 41%
Pediatric
Respiratory 7,552 5,036 67% 4,371 58%
Cardiac 8,374 5,594 67% 4,265 51%
ECPR 2,996 1,645 55% 1,232 41%
Adult
Respiratory 10,601 6,997 66% 6,121 58%
Cardiac 9,025 5,082 56% 3,721 41%
ECPR 2,885 1,137 39% 848 29%
Total 78,397 54,866 70% 45,345 58%
Fig. 1. Active extracorporeal membrane oxygenation Centers and patients reported to the Extracorporeal Life Support Organization
9000 8000 7000 6000 4000
there has been continued increase in the number of Centers performing ECMO (Fig. 1) and in the amount of pediatric and neonatal use in children with cardiac disease as well as a large increase in the use of ECMO for adult respiratory and cardiac disease (Table 2). In 2011, we initiated the first ECMO program in Kazakhstan. Use of ECMO in newborns and infants is well established, and the modality has been increasingly applied in complex adult populations for indications including acute respiratory failure, acute heart failure, acute coronary syndrome, and cardiogenic shock after cardiac procedures, including percutaneous coronary intervention, cardiac surgery, and heart-lung transplantation [3-9]. In 2012, we initiated experience of applying off-Center ECMO by mobile team employing a novel bedside approach, using echocardiography guided single-site cannulation with a bicaval, dual-lumen catheter.
This paper describes the initial experience and early outcomes of applying VA-VV ECMO in our Center.
Methods
We performed a retrospective analysis of 203 patients, to evaluate clinical outcomes after ECMO Between May 2011 and September 2016. The primary outcome was all-cause mortality. Secondary outcome measures included stroke, bleeding, and acute kidney injury. Stroke was defined as any cerebrovascular event in which either a postoperative iatrogenic complication on the index admission or a primary diagnosis of a hemorrhagic or ischemic cerebrovascular event of any subsequent admission was recorded. This definition excluded transient ischemic attacks. Major bleeding events were identified by a diagnosis of postoperative bleeding, intracerebral hemorrhage, hemopericardium, cardiac tamponade, gastrointestinal hemorrhage, hematuria, hemarthrosis, hemoptysis, epistaxis, or retinal or choroidal hemorrhage during the index admission or requiring subsequent hospital admission within 30 days. Acute kidney injury was defined as a diagnosis of acute renal failure because of nontraumatic causes during the index admission or as a primary diagnosis on any subsequent admission within 30 days.
Table 2. Extracorporeal membrane oxygenation use in runs per year (survival, %). Run time in hours
2011 2012 2013 2014 2015 2016
Respiratory
Neonatal 851 (66%) 856 (70%) 786 (67%) 893 (70%) 813 (63%) 227 (61%)
Paediatric 413 (59%) 476 (63%) 495 (62%) 497 (62%) 561 (60%) 218 (61%)
Adult 687 (58%) 973 (57%) 1,468 (60%) 1,961 (61%) 2,046 (57%) 929 (59%)
Cardiac
<16 years old 889 (52%) 916 (52%) 978 (50%) 1,063 (50%) 807 (50%) 298 (45%)
>16 years old 621 (37%) 1,066 (41%) 1,259 (41%) 1,758 (43%) 2,167 (42%) 703 (38%)
Пя Ю.В., Калиев Р.Б., Лесбеков Т.Д., Бекбосынов С.Т., Капышев Т.С., Нурмыхаметова Ж.А., Смагулов Н.К., Аширов Ж.З., Фаизов Л.Р. ■ ПРОГРАММА ЭКСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИЙ В КАЗАХСТАНЕ: БЛИЖАЙШИЕ РЕЗУЛЬТАТЫ
Table 3. Description of indication categories and diagnostic criteria
Indication Category Diagnostic Criteria
Complications after heart transplant Heart transplant before ECMO during index hospitalization
Acute coronary syndrome Diagnosis code on admission indicative of acute myocardial infarction, or percutaneous coronary intervention anytime during index admission, or ECMO preceding coronary artery bypass graft procedure during index admission
Circulatory collapse following a cardiac procedure ECMO on the day of or following cardiac procedure, including valve operation, coronary bypass graft procedure, and repair or dissection and aneurysm, during index admission
Acute heart failure Diagnosis code on index admission indicative of acute cardiac failure, or ECMO with or without cardiac procedure, including valve operation, coronary bypass graft procedure, and repair or dissection and aneurysm during index admission
Respiratory failure Diagnosis code on admission indicative of acute respiratory failure, or lung transplant during index admission
Results
A total of 203 patients had venovenous and venoarterial extracorporeal membrane oxygenation performed, of these, adult 141 patients at a median age of 47 (22-77) years old, EuroScore II - 7 (4-18), Pregnant - 8. General survival was 56%, adult - 60%, pediatric - 44%, transported patients - 47%. Indication for extracorporeal membrane oxygenation was respiratory failure in 23 (11%) patients, acute coronary syndrome 7 (3.4%) patients: post transplant - patients 19 (9.3)%, post-cardiac procedure - patients 134 (66%), acute heart failure in patients 15 (7.3%) (Table 4). Complications on ECMO are very common and as expected it is associated with significant increase in morbidity and mortality (Table 5). Patients outcomes is shown in Fig. 4.
Discussion
ECMO can be used to salvage patients with refractory heart or pulmonary failure who would otherwise have not survived.
Cardiogenic shock is a major complication after cardiac surgical intervention, especially in those with preoperative heart failure or cardiogenic shock [7-10]. In our centre, ECMO therapy is a valuable option for the treatment of severe low output syndrome and haemodynamic collapse.
ECMO should be employed early once postcardi-otomy cardiogenic shock is suspected. Recent studies report in-hospital survival rates with the use of ECMO ranging from 20% to 50% and mortality rates of 50-70% [7, 9]. In our study, there was an acceptable in-hospital mortality of 42.8%.
Table 4. Patient characteristics and indications in our Centre
General characteristic
Total 203
Adult 141
Pediatric 62
Central 160
Peripheral 43
V-A 173
V-V 29
ECMO duration (days) 9 (SD 9.7)
Table 5. Patient complications in our Centre
Complications n %
Sepsis 9 5.4
Stroke 3 1.8
Bleeding 22 13.4
Cannule dislocation 5 3
Circuit Thrombosis 6 3.6
Acute kidney injury 31 18.9
This article describes a retrospective analysis of our clinical experience. Despite a relatively high mortality rate, we remain confident that the ECMO is a strong alternative for those who stay refractory for maximal conventional therapy. No doubts, good general postoperative care, proper organization and implementation, continuous learning should be emphasized to prevent the complications of ECMO and to improve patients' outcomes. Because of the advance-
Fig. 2. ECMO indications
Fig. 3. Extracorporeal membrane oxygenation use per year in our Center
53
ECMO performance
ita ■ ■ _o]_
Pediatric Adult Explantation Survival Mobile ECMO
□ 2011 ■ 2012 □ 2013 ■ 2014 ■ 2015
2016
Fig. 4. Patient outcomes in our Centre
250 200 150 100 50
2011 2012 2013 2014 2015 2016
- ECMO cases 1 27 75 128 169 203
---Weaning from ECMO 1 11 39 81 104 129
Discharged from ECMO 0 4 29 69 93 113
---Mortality 1 23 46 59 76 87
ment of the ECMO equipment, including oxygenators, biomechanical pumps and heparin coated tubes, the complications could be overcome.
Our analysis has several limitations: it is non randomized, retrospective, single Center research.
References
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Conclusion
Our results reflect findings from previous studies and ELSO registry. Further research in this direction will be helpful to understand outcomes in different clinical subgroups.
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