Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections

Aristine Cheng; Hsin-Yun Sun; Mao-Song Tsai; Wen-Je Ko; Pi-Ru Tsai; Fu-Chang Hu; Yee-Chun Chen; Shan-Chwen Chang

doi:10.1016/j.jtcvs.2016.08.038

Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections

J Thorac Cardiovasc Surg. 2016 Dec;152(6):1526-1536.e1. doi: 10.1016/j.jtcvs.2016.08.038. Epub 2016 Aug 30.

Authors

Aristine Cheng¹, Hsin-Yun Sun², Mao-Song Tsai³, Wen-Je Ko⁴, Pi-Ru Tsai⁵, Fu-Chang Hu⁵, Yee-Chun Chen², Shan-Chwen Chang⁶

Affiliations

¹ Department of Medicine, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan; Department of Medicine, National Taiwan University Hospital, Main Branch and College of Medicine, Taipei, Taiwan.
² Department of Medicine, National Taiwan University Hospital, Main Branch and College of Medicine, Taipei, Taiwan.
³ Department of Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan.
⁴ Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.
⁵ International Harvard Statistical Consulting Company, Taipei, Taiwan.
⁶ Department of Medicine, National Taiwan University Hospital, Main Branch and College of Medicine, Taipei, Taiwan. Electronic address: changsc@ntu.edu.tw.

PMID: 27692951
DOI: 10.1016/j.jtcvs.2016.08.038

Abstract

Background: To identify novel factors associated with the survival of septic adults receiving extracorporeal membrane oxygenation (ECMO) to improve patient selection and outcomes.

Methods: Cases were identified from our ECMO registry from 2001 to 2011 if they were ≥16 years and received ECMO for life-threatening sepsis.

Results: A total of 151 adults with a median (25th-75th percentile) age of 51 (37-63) years were analyzed. Pneumonia (50%), myocarditis (20%), and primary bloodstream infections (15%) were the main types of infection, caused by predominantly nonfermentative Gram-negative bacteria (NFGNB) (26%), Enterobacteriaceae (24%), and Gram-positive cocci (21%). The in-hospital mortality of patients with NFGNB, enteric, and Gram-positive bacterial pneumonias were 100%, 68%, and 14%, respectively. Using the Cox-proportional hazards model, we found that age >75 years (hazard ratio [HR], 1.98, 95% confidence interval [95% CI], 1.30-3.02), pre-ECMO dialysis (HR, 3.20, 95% CI, 1.34-7.63), longer door-to-ECMO intervals (HR, 1.01, 95% CI, 1.00-1.02), venoarterial mode (HR, 2.58, 95% CI, 1.55-4.21), and fungal (HR, 2.83, 95% CI, 1.36-5.88) and NFGNB sepsis (HR, 2.48, 95% CI, 1.44-4.27) were associated with mortality. Gram-positive sepsis (HR, 0.20, 95% CI, 0.08-0.57), myocarditis (HR, 0.12, 95% CI, 0.06-0.27), pneumonia (HR, 0.54, 95% CI, 0.30-0.90), and effective empirical antimicrobial therapy were predictive of survival (HR, 0.57, 95% CI, 0.37-0.89); all P < .05. Excluding the 67 heavily premorbid patients, we found that 54% survived ECMO and 42% survived to discharge, with significantly more survivors with door-to-ECMO times of ≤96 hours than >96 hours (59% vs 15%, P < .0001).

Conclusions: Better outcomes were associated with door-to ECMO times of 96 hours or less, for Gram-positive rather than Gram-negative sepsis, and for pneumonia rather than primary bloodstream infections.

Keywords: ARDS; community-acquired pneumonia; early rescue; extracorporeal life support; infections; sepsis; shock.

MeSH terms

Adult
Extracorporeal Membrane Oxygenation*
Hospital Mortality
Humans
Male
Middle Aged
Patient Selection
Sepsis / mortality*
Sepsis / therapy*
Survival Rate
Time-to-Treatment