Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations' ECMO case registry

Lindsay Weiner, Michael A Mazzeffi, Elizabeth Q Hines, David Gordon, Daniel L Herr, Hong K Kim
Clinical Toxicology 2019 October 16, : 1-6
Background: Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is increasingly utilized to treat severe or refractory drug-induced cardiovascular shock. There is limited evidence regarding VA-ECMO's clinical utility in poisoning. Therefore, we investigated the clinical benefit of VA-ECMO use in drug-induced cardiovascular shock using the Extracorporeal Life Support Organization (ELSO)'s ECMO case registry. Methods: The ELSO registry was systematically searched retrospectively, using ICD-9/10 codes for poisoning-related cases from January 1, 2003 to July 30, 2018. All adult cases (age ≥ 18 years) that received VA-ECMO for cardiac support were included. Cardiogenic shock was defined as systolic blood pressure (SBP) <90 mmHg, mean arterial pressure (MAP) <65 mmHg, or requiring infusion of ≥2 vasopressor agents. Study outcomes included survival to discharge (i.e., from the ECMO center), changes in metabolic (acid/base), hemodynamic and ventilatory status, and complications related to ECMO support. Demographic and clinical characteristics of pre-ECMO and 24-h after VA-ECMO cannulation were compared between survivors vs. non-survivors. Results: A total of 113 cases were identified from the ELSO registry; 9 cases were excluded because cardiogenic shock was not related to poisoning, leaving 104 cases for analysis. The median age was 34 years and 53.5% ( n  = 54) were male. Cardiovascular agents were involved in 47.1% ( n  = 49) of the cases followed by opioids ( n  = 9, 6.7%); 34 cases experienced pre-ECMO cardiac arrest. About 92.4% of the cases ( n  = 85) received vasopressor infusion for hemodynamic support, most frequently norepinephrine (83.7%). Median duration of VA-ECMO was 68 h (interquartile range [IQR]: 48, 113 h); 52.9% ( n  = 55) of the cases survived to discharge. VA-ECMO significantly improved hemodynamics (MAP, SBP, and DBP), acidemia/acidosis (pH, HCO3 level) and ventilatory parameters (pO2 , SpO2 , and SvO2 ). Non-survivors showed persistent acidemia/acidosis at 24-h after VA-ECMO cannulation compared to survivors. Renal replacement therapy (50.9%) and arrhythmia (26.3%) were the most frequently reported complications. Conclusions: VA-ECMO improved hemodynamic and metabolic parameters in patients with drug-induced cardiogenic shock (DCS).

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