Improvements in Vasopressor Requirements With Venovenous Extracorporeal Membrane Oxygenation

CHEST critical care Pub Date : 2024-11-19 DOI:10.1016/j.chstcc.2024.100111

Mazen F. Odish MD , Travis Pollema DO , Alex Ignatyev BS , Jerry Lipinski MD , Cassia Yi MSN , Michelle Parrett BSN , Khang Tong MS , Lin Liu PhD , Atul Malhotra MD , Robert L. Owens MD

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Abstract

Background

Venovenous extracorporeal membrane oxygenation (ECMO) is used increasingly for severe respiratory failure. Some ECMO clinicians may view concurrent vasopressors as a contraindication for venovenous ECMO. However, we noted improved vasopressor requirements after venovenous ECMO cannulation.

Research Question

How does venovenous ECMO affect vasopressor requirements in patients with respiratory failure?

Methods

This was a retrospective review of all venovenous ECMO initiations from December 2016 through December 31, 2023, at a large-volume ECMO center. The changes in norepinephrine equivalent dose and number of continuous IV vasopressors were determined immediately before and 24 hours after venovenous ECMO cannulation. This change was assessed by Wilcoxon signed-rank tests, and their associations with potential predictor variables (pH, Paco₂, Pao₂, and positive end-expiratory pressure) were examined by linear regressions.

Results

Two hundred five patients received venovenous ECMO during this time, with 108 patients taking vasopressors at ECMO cannulation and included in this analysis. The mean (SD) norepinephrine equivalent dose at ECMO initiation, 0.23 (0.29) μm/kg/min, to 24 hours after ECMO, 0.14 (0.23) μm/kg/min, decreased significantly (P < .001). The mean (SD) number of pressors at ECMO initiation, 1.69 (0.92), to 24 hours later, 1.29 (1.04), decreased significantly (P < .001). A significant decrease in positive end-expiratory pressure, mean airway pressure, and Paco₂ with a significant increase in pH and Pao₂ was found (P ≤ .001 for all). The changes in pH (P < .001) were associated with changes in norepinephrine equivalent dose and number of vasopressors after adjusting for baseline outcomes. Twenty-seven patients (25%) had received a norepinephrine equivalent dose of ≥ 0.3 μm/kg/min at ECMO initiation; of these, 16 patients (59.3%) survived to hospital discharge (compared with 51.9% survival among those with a lower norepinephrine equivalent dose at ECMO initiation; P = .66).

Interpretation

Our results show that patients’ vasopressor requirements significantly decreased 24 hours after venovenous ECMO initiation, with a change in pH weakly associated with vasopressor improvement. The requirement of vasopressors, even norepinephrine equivalent dose of ≥ 0.3 μm/kg/min at the time of ECMO consideration, is not a clear contraindication to ECMO candidacy.

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静脉-静脉体外膜氧合改善血管加压素需求

背景静脉-静脉体外膜氧合（ECMO）越来越多地用于严重呼吸衰竭。一些ECMO临床医生可能将并发血管加压药物视为静脉-静脉ECMO的禁忌症。然而，我们注意到静脉-静脉ECMO插管后血管加压药的需求有所改善。研究问题：静脉-静脉ECMO如何影响呼吸衰竭患者的血管加压素需求？方法回顾性分析2016年12月至2023年12月31日在大容量ECMO中心进行的所有静脉-静脉ECMO启动。测定静脉-静脉ECMO置管前和置管后24h去甲肾上腺素当量剂量和持续静脉加压药物数量的变化。通过Wilcoxon sign -rank检验评估这种变化，并通过线性回归检验其与潜在预测变量（pH、Paco2、Pao2和呼气末正压）的相关性。结果125例患者在此期间接受了静脉-静脉ECMO，其中108例患者在ECMO插管时服用了血管加压药物。ECMO起始时去甲肾上腺素平均当量（SD）为0.23 (0.29)μm/kg/min， ECMO后24 h为0.14 (0.23)μm/kg/min，显著降低(P <；措施)。ECMO开始时的平均（SD）压力数为1.69(0.92)，至24小时后的平均（SD）压力数为1.29(1.04)，显著降低(P <；措施)。呼气末正压、平均气道压、Paco2均显著降低，pH、Pao2均显著升高（P≤0.001）。pH (P <；.001)与基线结果调整后去甲肾上腺素当量剂量和血管加压药物数量的变化相关。27例（25%）患者在ECMO开始时接受了去甲肾上腺素当量剂量≥0.3 μm/kg/min；其中，16名患者（59.3%）存活至出院(相比之下，ECMO开始时使用较低去甲肾上腺素当量剂量的患者生存率为51.9%；P = .66)。我们的研究结果表明，在静脉-静脉ECMO开始24小时后，患者的血管加压素需求显著降低，pH值的变化与血管加压素的改善弱相关。在考虑ECMO时，血管加压药的要求，即使是去甲肾上腺素当量剂量≥0.3 μm/kg/min，也不是候选ECMO的明确禁忌症。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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CHEST critical care Critical Care and Intensive Care Medicine, Pulmonary and Respiratory Medicine

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