Venoarterial extracorporeal membrane oxygenation support for refractory cardiovascular dysfunction during severe bacterial septic shock

Nicolas Bréchot, Charles-Edouard Luyt, Matthieu Schmidt, Pascal Leprince, Jean-Louis Trouillet, Philippe Léger, Alain Pavie, Jean Chastre, Alain Combes
Critical Care Medicine 2013, 41 (7): 1616-26

OBJECTIVES: Profound myocardial depression can occur during severe septic shock. Although good outcomes of venoarterial extracorporeal membrane oxygenation-treated children with refractory septic shock have been reported, little is known about adults' outcomes. This study was designed to assess the outcomes and long-term health-related quality-of-life of patients supported by venoarterial extracorporeal membrane oxygenation for refractory cardiac and hemodynamic failure during severe septic shock.

DESIGN: A retrospective, single-center, observational study and a cross-sectional survey to assess health-related quality of life by the Short Form-36 questionnaire and frequencies of anxiety, depression and posttraumatic stress disorder symptoms by the Hospital Anxiety and Depression Scale and the Impact of Event Scale, respectively.

SETTING: A 26-bed tertiary intensive care unit in a university hospital.

PATIENTS: We evaluated the outcomes of patients who received venoarterial extracorporeal membrane oxygenation rescue therapy for refractory cardiovascular failure during bacterial septic shock. Results are expressed as medians (range).

MEASUREMENTS AND MAIN RESULTS: From January 2008 to September 2011, 14 patients, 45 years old (28-66), seven males, none with a history of left ventricular dysfunction, received venoarterial extracorporeal membrane oxygenation for septic shock refractory to conventional treatment, 24 hours (3-108) after shock onset. All exhibited severe myocardial dysfunction at extracorporeal membrane oxygenation implantation. Left ventricular ejection fraction was 16% (10% to 30%), cardiac index was 1.3 L/min/m (0.7-2.2 ) and systemic resistance vascular index was 3162 (2047-7685). All were receiving high-dose catecholamines and had signs of multiple organ failure: pH 7.16 (6.68-7.39), blood lactate 9 (2-17) mmol/L, PaO2/FIO2 87 (28-364), Simplified Acute Physiology Score III 84 (75-106) and Sepsis-Related Organ Failure Assessment score 18 (8-21). Twelve patients (86%) could be weaned off venoarterial extracorporeal membrane oxygenation after 5.5 days (2-12) days of support and 10 patients (71%) were discharged to home and were alive after a median follow-up of 13 months (3-43). All 10 survivors had normal left ventricular ejection fraction and reported good health-related quality of life at long-term follow-up.

CONCLUSIONS: Venoarterial extracorporeal membrane oxygenation rescued more than 70% of the patients who developed refractory cardiovascular dysfunction during severe bacterial septic shock. Survivors reported good long-term quality of life. Venoarterial extracorporeal membrane oxygenation might represent a valuable therapeutic option for adults in severe septic shock with refractory cardiac and hemodynamic failure.

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