A simple VA-ECMO bundle in adult patients with cardiogenic shock: an analysis of ELSO registry.

Abstract

Background: The optimal management strategy for patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock (CS) remains uncertain. To evaluate the impact of "bundled" physiologic targets on outcomes in VA-ECMO patients.

Methods: This retrospective cohort study analyzed data from the Extracorporeal Life Support Organization (ELSO) registry, including adult patients receiving VA-ECMO for CS between 2013 and 2022. Patients were grouped by whether they received the full set of bundle components within the first 24 h. The bundle included mean arterial pressure > 65 mmHg, PaO₂ 60-150 mmHg, relative change in PaCO₂ [RelΔCO₂] > -50% (RelΔCO₂ = [(PaCO_2-24hours-PaCO_2-baseline)/PaCO_2-baseline] ∗ 100%), and peak inspiratory pressure < 30 mmHg. The primary outcome was survival to hospital discharge, while secondary outcomes were complications.

Findings: Of 7950 patients (mean age 56.5 ± 14.3 years), 2762 (34.7%) received the complete bundle. The bundle group had significantly higher rates of survival to hospital discharge (55.9% vs. 39.4%, p < 0.001) with adjusted odds ratio [aOR] of 1.849 (95% CI [1.675, 2.042]; p < 0.001), and the likelihood of brain death (aOR = 0.521, 95% CI: 0.289-0.885; p = 0.021), ischemic stroke (aOR = 0.710, 95% CI: 0.559-0.896; p = 0.004), hemorrhagic complications (aOR = 0.773, 95% CI: 0.681-0.876; p < 0.001) and cardiovascular complications (aOR = 0.863, 95% CI: 0.770-0.966; p = 0.011) were reduced.

Interpretation: Achieving the proposed physiologic bundle is associated with improved survival and a reduced risk of complications in VA-ECMO patients with CS. These findings provide evidence supporting the use of standardized care bundles in the management of VA-ECMO patients with CS.

Funding: This work was supported by the Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support (No. ZYLX202111, to X Hou), Beijing Hospitals Authority "Ascent Plan" (No. FDL20190601, to X Hou), Young Elite Scientists Sponsorship Program by CAST (No. 2022QNRC001, to L Wang), National Natural Science Foundation of China (No. 82200433, to L Wang), and Beijing Hospitals Authority Youth Programme (No. QML20230602, to L Wang), National Natural Science Foundation of China (No. 82100408, to X Hao), Beijing Nova Program (No. 2022064, to C Li), Beijing Natural Science Foundation (No. 7244327, to C Li), and the National Key Research and Development Program of China (No. 2021YFC2701700 and 2021YFC2701703, to Z Du).