Discharge Outcome in Adults Treated With Extracorporeal Membrane

Oxygenation
Jane Guttendorf, Arthur J. Boujoukos, Dianxu Ren, Margaret Q. Rosenzweig and Marilyn
Hravnak
Am J Crit Care 2014;23:365-377 doi: 10.4037/ajcc2014115
© 2014 American Association of Critical-Care Nurses
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Critical Care Techniques

D OUTCOME
ISCHARGE
IN ADULTS TREATED WITH
EXTRACORPOREAL
MEMBRANE OXYGENATION
By Jane Guttendorf, RN, DNP, ACNP-BC, Arthur J. Boujoukos, MD, Dianxu Ren, MD,
PhD, Margaret Q. Rosenzweig, RN, PhD, FNP-BC, and Marilyn Hravnak, RN, PhD,
ACNP-BC

Background Extracorporeal membrane oxygenation (ECMO)

is used for critically ill patients when conventional treatments
for cardiac or respiratory failure are unsuccessful.
Objectives To describe patient and treatment characteristics
and discharge outcome for ECMO patients, determine which
characteristics are associated with good (survival) versus poor
(death before hospital discharge) outcomes, and compare
characteristics of patients with cardiac versus respiratory failure
indicating ECMO.

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1. Describe the medical indications for the use of
extracorporeal membrane oxygenation
(ECMO).
2. Identify the complications associated with
ECMO.
3. Discuss the outcomes associated with ECMO.
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©2014 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2014115
Methods Single-center, retrospective review of all adult
patients treated with ECMO from 2005 through 2009.
Results A total of 212 patients received ECMO for cardiac (n =
126) or respiratory (n = 86) failure. Mean age was 51 (SD, 14.5)
years; support duration was 135 (SD, 149) hours. Survival to
discharge was 33% overall; 50% for respiratory indication and
21% for cardiac indication patients. Patients with poor outcomes
were older (53 vs 47 years, P = .007), more likely to require car-
diovascular support before ECMO (99% vs 91%; P = .02), and
had more transfusions (48 vs 24 units, P = .005) and complica-
tions (99% vs 87%; P < .001) than did patients with good out-
comes. For cardiac patients, older age was associated with poor
outcome (poor, 55 vs good, 48 years; P = .01). For respiratory
patients, poor outcome was associated with more ventilator
days before ECMO (poor, 6 vs good, 3; P = .01), higher peak
inspiratory pressure (poor, 39 vs good, 35 cm H2O; P = .02), and
lower pulmonary compliance (poor, 19 vs good, 25 mL/cm H2O;
P = .008).
Conclusions Patients with respiratory indications for ECMO
experienced better survival than did cardiac patients. Increas-
ing age was associated with poor outcome. Complications,
regardless of ECMO indication, were common and associated
with poor outcome. (American Journal of Critical Care. 2014;
23:365-377)

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 E
xtracorporeal membrane oxygenation (ECMO) is a rescue therapy to support
patients with acutely life-threatening cardiac and/or respiratory dysfunction when
conventional therapies fail. During ECMO, blood is continuously circulated
extracorporeally via a blood pump, passed through a membrane oxygenator for
oxygen uptake and carbon dioxide elimination, and then returned to the patient.
This complex system serves only as supportive therapy, allowing time for the heart and lungs
to rest, recover, and heal. ECMO use can extend from days to weeks. Recently, trends in using
ECMO for longer durations across a broader range of indications have challenged clinicians
to respond creatively in meeting the demands of patients undergoing ECMO.

Although long recognized as a successful therapy
in neonates,1,2 ECMO has lately been used increas-
ingly in adults as a rescue therapy for acute lung
injury (ALI), acute respiratory distress syndrome
(ARDS), and severe acute respiratory failure.1-9 It has
also been used in the treatment of acute cardiac
failure due to cardiogenic shock (acute myocardial
infarction, ischemic and nonischemic cardiomyopa-
thy, myocarditis, pulmonary embolus, and cardiac
arrest) and for postcardiotomy syndromes (failure
to wean from cardiopulmonary bypass following
cardiac surgery).1,2,10-12 ECMO is now also used in
adults as a rescue therapy to bridge
to heart, lung, or heart-lung trans-
ECMO use for plant, as rescue therapy from primary
longer durations graft dysfunction (PGD) after trans-
plant, and to bridge patients with
for broader indi- acute cardiac failure to support with
cations has chal- a ventricular assist device.13-18
ECMO is effective, but the rates
lenged clinicians. of therapy-related morbidity and
mortality are high, and ECMO is
associated with significant resource utilization. Given
the high-risk, complexity, and cost of care in the
face of an expanding list of indications, we sought
About the Authors
Jane Guttendorf is an acute care nurse practitioner at
University of Pittsburgh Medical Center and an assistant
professor at University of Pittsburgh School of Nursing,
Pittsburgh, Pennsylvania. Arthur J. Boujoukos is an inten-
sivist at University of Pittsburgh Medical Center and a
professor in the Department of Critical Care Medicine at
University of Pittsburgh School of Medicine. Dianxu Ren
is an associate professor and Margaret Q. Rosenzweig
is an associate professor at University of Pittsburgh School
of Nursing. Marilyn Hravnak is an acute care nurse prac-
titioner at University of Pittsburgh Medical Center and a
professor at University of Pittsburgh School of Nursing.
Corresponding author: Jane Guttendorf, RN, DNP, ACNP-BC,
University of Pittsburgh School of Nursing, Department
of Acute and Tertiary Care, 336 Victoria Building, 3500
Victoria Street, Pittsburgh, PA 15261 (e-mail: jag117
@pitt.edu).
to evaluate our ECMO care outcomes and determine
if any baseline or treatment characteristics were
associated with better outcomes.
Our purpose was to (1) describe patient charac-
teristics (demographics, indication, comorbid con-
ditions, physiological variables before ECMO),
treatment characteristics (duration, mode, cannula-
tion, transfusion, complications), and outcomes
(good outcome is survival to discharge) of the total
sample of patients supported with ECMO in a major
referral center, (2) determine which characteristics
of patients and treatments were associated with a
good versus a poor outcome, and (3) determine if
the characteristics associated with good versus poor
outcome differed between patients with a cardiac
versus a respiratory indication for support.
Methods
Setting and Sample
This descriptive study used a retrospective review
of all adult patients treated with ECMO in 5 years
(from January 1, 2005 to December 31, 2009) at the
University of Pittsburgh Medical Center Presbyterian
Hospital, a tertiary care and ECMO referral center,
and was conducted with approval of the UPMC Qual-
ity Improvement Review Committee. Patients were
identified from our perfusion services database. Of
the 217 patients treated with ECMO within the time
frame, 5 patients were excluded (in 2 patients, ECMO
flow could not be established; in 2 patients, the
ECMO course was less than 1 hour; and in 1 patient
with 2 ECMO interventions for different indications
in the same hospitalization, the data points were
overlapping), leaving a final sample of 212 patients.
Data Collection and Variables of Interest
Electronic medical records were reviewed by
the primary investigator (J.G.) for specific charac-
teristics of patients and treatments.
Patient characteristics were variables related
to patients at baseline or care before ECMO:

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demographics, weight, body mass index (calculated
as body weight in kilograms divided by height in
meters squared), primary ECMO indication (cardiac
or respiratory failure), left ventricular ejection frac-
tion (LVEF), Charlson Comorbidity Index (CCI, Deyo
method), mechanical ventilator and blood gas param-
eters before ECMO (ventilator days, Murray ALI score,
pH, ratio of PaO2 to fraction of inspired oxygen (FIO2),
compliance, peak inspiratory pressure, positive end-
expiratory pressure, and tidal volume/kg), adjunctive
therapies before ECMO for respiratory (bagging, nitric
oxide, high-frequency ventilation, proning, neuro-
muscular blockade) and cardiovascular (pressors,
inotropes, intra-aortic balloon pump, ventricular
assist device, cardiopulmonary resuscitation/defib-
rillation) support.
Treatment characteristics were variables related
to care needs during ECMO: ECMO hours, venoar-
terial cannulation (vs venovenous), central cannula-
tion (vs peripheral), transfusion requirement, hospital
length of stay, and complications (bleeding, neuro-
logical problems, renal failure requiring dialysis, liver
dysfunction, multisystem organ dysfunction (MSOF)/
shock, arrest, vascular, and infection) while undergo-
ing ECMO and within 2 weeks after ECMO treatment.
Indications for use of ECMO were categorized
as either a primary cardiac failure or a primary res-
piratory failure. Cardiac indication subgroups were
cardiogenic shock (acute myocardial infarction,
nonischemic cardiomyopathy, cardiopulmonary
resuscitation, pulmonary embolus, myocarditis,
ischemic cardiomyopathy), postcardiotomy syndrome,
and heart or heart-lung transplant recipients. Respi-
ratory indication subgroups were ARDS (aspiration,
pulmonary edema/transfusion-associated lung
injury, contusion, pneumonia, hypercapnia), bridge
to lung transplant, PGD after lung transplant, and
other causes of respiratory failure.
LVEF was determined when available from the
medical record, using the study closest to the time
before ECMO or within 48 hours after the start of
ECMO. The CCI was used to assess comorbidity
burden by using the method adapted by Deyo et
al,19 which is based on coding from the International
Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9).19 ICD-9 codes were evaluated
for 17 comorbidity categories and scored for each
category, then given a cumulative score. CCI scores
of 5 or greater have been associated with higher
mortality and complications related to comorbidity
in hospitalized patients.20,21 The Murray ALI score
was assigned by the principal investigator according
to previously described methods.22 Transfusion
included the total number of blood products trans-
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fused during ECMO (packed red blood cells, plasma,
platelets, and cryoprecipitate).
ECMO mode and cannulation were determined.
Venovenous mode included cannulation techniques
routing blood from vein to vein
(femoral vein to femoral vein, Electronic med-
femoral vein to internal jugular
vein, dual-lumen cannulation of ical records were
the internal jugular vein). Venoar-
terial mode involved routing blood
used to gather
from vein to artery and included data on patient
peripheral (femoral vein to femoral
artery) or central cannulation. Cen-
and treatment
tral cannulation involved drainage characteristics.
cannula sites in the superior or
inferior vena cava or right atrium and return cannula
sites in the aorta, left atrium, and pulmonary or
subclavian arteries.
Complications were determined by reviewing
clinical and operative notes, microbiology and elec-
troencephalography reports, ICD-9 admission codes,
and autopsy reports if within the ECMO/2-week-
after-ECMO window. Bleeding complications were
hemothorax, mediastinal/tamponade, pulmonary/
airway, gastrointestinal, retro/intraperitoneal, hema-
turia requiring continuous irrigation or procedure,
and epistaxis (requiring packing or procedure).
Neurological complications were intracranial hem-
orrhage, stroke (embolic or ischemic), seizure
(clinical or electroencephalography note), and
encephalopathy. Renal failure was coded if dialysis
or renal replacement therapy was initiated. Liver
dysfunction and MSOF/shock were coded if noted
in clinical notes, autopsy reports, or ICD-9 coding.
Arrest included cardiac or respiratory arrest requir-
ing resuscitation, cardiopulmonary resuscitation,
or defibrillation, but excluded elective cardiover-
sion. Vascular complications included vessel injury
requiring repair, intestinal or limb ischemia, or
amputation. Infection included pneumonia (posi-
tive culture plus treatment), blood stream infection
(positive culture), and mediastinitis (positive culture
plus treatment) from clinical note and/or microbi-
ology report.
Outcome was determined by survival to hospi-
tal discharge (good outcome), whereas poor out-
come was death in hospital or being discharged to
terminal hospice care (2 patients). Six-month and
1-year survival after ECMO were recorded.
Analyses
Statistical analyses were performed by using IBM
SPSS version 20 (SPSS Inc). Missing data fields were
not replaced. Continuous variables were reported as
367
 mean with standard deviation, and continuous vari-
ables were compared between outcome groups by
using a Student t test (normally distributed data) or
a Mann-Whitney U test (for data not normally dis-
tributed) as appropriate. Categorical variables were
reported as frequencies with percentages, with cate-
gorical variables compared between the good and
poor outcome groups by using χ2
tests or the Fisher exact test as
Mean ECMO appropriate. All tests were 2-sided,
and P less than .05 was considered
duration was statistically significant.
135 hours; 95%
Results
of patients Of the 212 eligible ECMO
experienced a patients in the study interval, 126
had a primary cardiac indication
complication. and 86 had a primary respiratory
indication. Cardiac indications were
cardiogenic shock (n = 55), postcardiotomy syndrome
(n = 48), and PGD after heart (n = 19) and heart-lung
(n = 4) transplant. Respiratory indications included
all-cause ARDS (n = 49), bridge to lung transplant (n =
8), PGD after lung transplant (n = 26), and other
causes of respiratory failure (n = 3).
Characteristics of the Total Sample
Characteristics of the total sample of patients
(Table 1) indicate that ECMO patients had a mean
age of 51 years and were predominantly white (94%)
and male (65%). LVEF averaged 41% (SD, 20%). The
CCI mean score was 3.66 (SD, 2.0). Mean days of
mechanical ventilation before ECMO was 3 (SD, 4),
and the Murray ALI score mean was 2.84 (SD, 1.0).
Nearly all patients required adjunctive respiratory
and cardiovascular supportive therapies before ECMO.
The most common respiratory
Patients with adjuncts were neuromuscular block-
ade (77%) and inhaled nitric oxide
acute respiratory (39%); the most common cardiovas-
distress syn- cular adjuncts were inotropes (96%)
and pressors (84%), IABP (40%), or
drome or bridge cardiopulmonary resuscitation/
to lung trans- defibrillation before ECMO (31%).
ECMO treatment characteristics
plant were more (Table 1) indicated a mean ECMO
duration of 135 (median, 88) hours
likely to have a and a mean of 40 units of blood
good outcome. products. Sixty-nine percent of
patients had venoarterial cannulation
(including all the cardiac indication patients), and
43% required central cannulation. More than 95%
of patients experienced a complication, the most com-
mon being renal failure requiring dialysis (61%),
368 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
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bleeding (58%), MSOF/shock (52%), infection
(49%), and neurological problems (47%).
Determination of Characteristics Associated
With Poor Versus Good Outcome After ECMO
in the Total Sample
Of the 212 patients, 57% were successfully
weaned from ECMO, 33% lived to discharge (good
outcome), and 28% were alive 1 year after ECMO.
Poor outcome (death in hospital) was experienced
by 142 patients (67%); 50 were successfully weaned
from ECMO but died later in hospitalization, and
92 died while undergoing ECMO. Patient and treat-
ment characteristics were compared between sub-
groups with poor vs good outcomes (Table 2).
Patients with poor outcomes were significantly older,
had a higher mean Murray ALI score, and required
more cardiovascular adjunctive therapies. Signifi-
cantly more patients with a cardiac indication for
ECMO had a poor outcome (70%) compared with
only 30% of patients with a respiratory indication
(P < .001). Outcome also differed for each detailed
indication for ECMO initiation. As shown in Figure
1, only patients with ARDS or bridge to lung trans-
plant were more likely to have a good than poor
outcome; a poor outcome was more prevalent for
all other indications. Respiratory indication patients
were more likely than cardiac indication patients to
be weaned successfully from ECMO (65% vs 51%),
survive to discharge (50% vs 21%), and be alive 1
year after ECMO (43% vs 18%). Figure 2 shows the
early and late outcome curves for the total sample
and for the cardiac and respiratory indication sub-
groups. Cardiac patients experienced a steeper decline
in survival over time than did respiratory patients,
most notably between the time of being weaned
from ECMO and hospital discharge. Cause of death
was predominantly MSOF (64%), neurological prob-
lems (16%), and cardiac failure (15%).
When examining ECMO treatment characteris-
tics by outcome status (Table 2), patients who had
a poor outcome had significantly higher transfusion
requirements than did patients who had a good
outcome, but hospital length of stay was higher in
patients who had a good outcome (48 vs 24 days,
P < .001). Significantly more patients who had a
poor outcome had venoarterial cannulation (75%
poor vs 56% good, P = .005) and central cannulation
(54% poor vs 21% good, P < .001). Bleeding com-
plications were similar in both poor and good out-
come subgroups, but patients who had a poor
outcome had significantly higher percentages of all
other complications except for infection (39% poor
vs 67% good, P < .001).
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Table 1
Patient and treatment characteristics for all 212 patients supported with
extracorporeal membrane oxygenation (ECMO)

Patient characteristic n No. (%)

Primary indication 212

Cardiac 126 (59.4)
Respiratory 86 (40.6)
Male sex 212 137 (64.6)
White race 212 199 (93.9)
Mean (SD) Range Median (IQR)

Age, years 212 51.2 (14.5) 16-83 52 (42-63)

Weight, kg 212 84.1 (22.9) 39-177 84 (68-97)
Body mass indexa 211 28.3 (6.8) 15-52.9 27.5 (23.4-32.4)
Ejection fraction, % 190 41 (20) 5-70 50 (20-55)
Charlson Comorbidity Index 207 3.66 (2.0) 0-10 4 (3-5)
Mechanical ventilator days, before ECMO 210 2.95 (4.1) 1-29 2 (1-3)
Murray Acute Lung Injury score 209 2.84 (1.0) 0-4 3 (2-3.75)
pH 197 7.26 (0.14) 6.74-7.74 7.26 (7.17-7.36)
Pao2/FIO2 ratio 193 132.1 (128.9) 19-732 73 (53-160)
Compliance, mL/cm H2O 183 24 (10.2) 4.1-57 22 (16.8-30.5)
Peak inspiratory pressure, cm H2O 185 34.1 (8.5) 15-59 33 (28-40)
Positive end-expiratory pressure, cm H2O 189 10.2 (5.6) 0-24 10 (5-15)
Tidal volume/kg, mL/kg 189 6.54 (2.2) 2.2-12.7 6.3 (4.87-8)
No. (%)

Respiratory adjuncts before ECMO, any 208 186 (89.4)

Bagging 53 (25.5)
Nitric oxide 80 (38.5)
High-frequency oscillatory ventilation 11 (5.3)
Prone positioning 5 (2.4)
Neuromuscular blockade 161 (77.4)
Cardiovascular adjuncts before ECMO, any 212 204 (96.2)
Pressor 203 (83.5)
Inotrope 177 (95.8)
Intra-aortic balloon pump 85 (40.1)
Ventricular assist device 19 (9.0)
Cardiopulmonary resuscitation/defibrillation 66 (31.1)
Treatment characteristic Mean (SD) Range Median (IQR)

ECMO hours 212 134.9 (149.4) 1-1155 88 (44.3-185)

Transfusion, total units 211 40 (51.8) 0-425 24 (10-54)
Hospital length of stay, days 212 31.8 (35.3) 1-254 21 (8-39)
No. (%)

Mode, any venoarterial 212 146 (68.9)

Cannulation, any central 212 92 (43.4)
Complications, any 212 202 (95.3)
Bleeding 122 (57.5)
Neurological problems 99 (46.7)
Renal failure requiring dialysis 129 (60.8)
Liver dysfunction 79 (37.3)
Multisystem organ failure/shock 111 (52.4)
Arrest 64 (30.2)
Vascular issues 72 (34.0)
Infection 103 (48.6)

Abbreviations: FIO2, fraction of inspired oxygen; IQR, interquartile range.

a Calculated as the weight in kilograms divided by the height in meters squared.

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Table 2
Comparison of patient and treatment characteristics for patients experiencing poor (n = 142)
and good (n = 70) outcomes after extracorporeal membrane oxygenation (ECMO)
Poor outcome (n = 142, 67%) Good outcome (n = 70, 33%)
Patient characteristic n No. (%) No. (%) P

Primary indication 212 <.001a

Cardiac 99 (69.7) 27 (38.6)
Respiratory 43 (30.3) 43 (61.4)
Male sex 212 88 (62) 49 (70) .29
White race 212 133 (93.7) 66 (94.3) >.99
n Mean (SD) n Mean (SD)

Age, years 212 53.1 (14.3) 47.4 (14.4) .007a

Weight, kg 212 83.79 (23.5) 84.75 (22.0) .77
Body mass indexb 211 141 28.28 (6.7) 70 28.22 (6.8) .95
Ejection fraction, % 190 131 40.8 (0.2) 59 40.0 (0.2) .78
Charlson Comorbidity Index 207 138 3.72 (2.1) 69 3.54 (2.0) .53
Mechanical ventilator days, before ECMO 210 142 3.27 (4.7) 68 2.29 (2.3) .17
Murray Acute Lung Injury score 209 140 2.74 (1.0) 69 3.04 (1.0) .02a
pH 197 134 7.25 (0.15) 63 7.27 (0.1) .48
PaO2/FIO2 ratio 193 131 139.26 (131.3) 62 116.82 (123.3) .30
Compliance, mL/cm H2O 183 122 23.34 (10.4) 61 25.28 (9.8) .23
Peak inspiratory pressure, cm H2O 185 124 33.85 (8.7) 61 34.67 (8.1) .54
Positive end-expiratory pressure, cm H2O 189 126 9.38 (5.3) 63 11.89 (5.8) .59
Tidal volume/kg, mL/kg 189 126 6.51 (2.2) 63 6.61 (2.1) .76
No. (%) No. (%)

Respiratory adjuncts before ECMO, any 208 129 (91.5) 57 (85.1) .23
Bagging 208 35 (24.8) 18 (26.9) .86
Nitric oxide 208 52 (36.9) 28 (41.8) .54
High-frequency oscillatory ventilation 208 8 (5.7) 3 (4.5) .76
Prone positioning 208 1 (0.7) 4 (6.0) .04a
Neuromuscular blockade 208 111 (78.7) 50 (74.6) .60
Cardiovascular adjuncts before ECMO, any 212 140 (98.6) 64 (91.4) .02a
Pressor 212 140 (98.6) 63 (90.0) .007a
Inotrope 212 124 (87.3) 53 (75.7) .048a
Intra-aortic balloon pump 212 68 (47.9) 17 (24.3) .001a
Ventricular assist device 212 18 (12.7) 1 (1.4) .009a
Cardiopulmonary resuscitation/defibrillation 212 51 (35.9) 15 (21.4) .04a
Treatment characteristic n Mean (SD) n Mean (SD)

ECMO hours 212 132.26 (145.1) 140.20 (158.5) .30

Transfusion, total units 211 141 47.84 (59.9) 70 24.13 (22.5) .005a
Hospital length of stay, days 212 23.82 (34.5) 47.86 (31.4) <.001a
No. (%) 70 No. (%)

Mode, any venoarterial 212 107 (75.4) 39 (55.7) .005a

Cannulation, any central 212 77 (54.2) 15 (21.4) <.001a
Complications, any 212 141 (99.3) 61 (87.1) <.001a
Bleeding 212 88 (62.0) 34 (48.6) .08
Neurological problems 212 86 (60.6) 13 (18.6) <.001a
Renal failure requiring dialysis 212 99 (69.7) 30 (42.9) <.001a
Liver dysfunction 212 68 (47.9) 11 (15.7) <.001a
Multisystem organ failure/shock 212 106 (74.6) 5 (7.1) <.001a
Arrest 212 54 (38.0) 10 (14.3) <.001a
Vascular issues 212 58 (40.8) 14 (20.0) .003a
Infection 212 56 (39.4) 47 (67.1) <.001a
Abbreviations: FIO2, fraction of inspired oxygen.
a Statistically significant.
b Calculated as the weight in kilograms divided by the height in meters squared.

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 50
45
40
Number of patients

35
30
25
20
15
10
5
0
n = 55 n = 48 n = 19 n=4 n = 49 n=8 n = 26 n=3
Cardiogenic Postcardiotomy Heart Heart-lung Adult respiratory Bridge to Lung Respiratory
shock syndrome transplant transplant distress lung transplant, other
syndrome transplant after

Poor outcome Good outcome

Figure 1 Indications for starting extracorporeal membrane oxygenation (ECMO) for patients with poor (n = 142) and
good (n = 70) outcomes.

Determination of Characteristics Associated 250

With Good Versus Poor Outcome on the
Basis of Cardiac or Respiratory Indication
for ECMO Support 200
Number of patients

Because patients with cardiac and respiratory

failure are not homogeneous with regard to need 150 250
for ECMO and response to ECMO support, we eval-
uated these subgroups separately with regard to
100
poor versus good outcome (Table 3) to determine
if the characteristics associated with a good outcome
might be different in the 2 groups. Of 126 patients 50
who had a cardiac indication, only 21% experi-
enced good outcome, whereas of 86 patients who
0
had a respiratory indication, 50% experienced a good All patients Survived Discharge Alive at Alive at
outcome. Age was significantly different in the cardiac ECMO outcome 6 months 1 year
subgroup (poor outcome older, P = .01), but not in good
the respiratory subgroup. LVEF was significantly dif-
ferent only in the cardiac subgroup, with the mean All ECMO patients Cardiac indication
LVEF higher for patients with a poor outcome (35%) Respiratory indication
than for patients with a good outcome (25%; P=.03).
In the respiratory indication subgroup, significant Figure 2 Comparisons of early and late outcomes for the total
differences were found between outcome groups for sample of extracorporeal membrane oxygenation (ECMO)
patients (n = 212), and those whose primary reason for ECMO
ventilator days before ECMO (6.1 days poor vs 2.8 was cardiac (n = 126) or respiratory (n = 86) dysfunction.
good, P = .01), compliance (19 mL/cm H2O poor vs
25 mL/cm H2O good, P = .008), and peak inspiratory
pressure (39 poor vs 35 cm H2O good, P = .02). no need for respiratory adjunctive therapy before
We performed multivariate logistic regression ECMO were significantly positively associated with
analysis for patient characteristics associated with good outcome. In patients with a respiratory indi-
good outcome in each ECMO indication subgroup cation for ECMO, more days of mechanical venti-
(Table 4). Variables significant at P less than .15 in lation before ECMO and higher peak inspiratory
univariate analysis were entered into the model, pressures were significantly negatively associated
which controlled for age, sex, and CCI. In patients with good outcome.
with a cardiac indication for ECMO, increased age For treatment characteristics, in the cardiac
was significantly negatively associated with a good indication subgroup (Table 3), patients who had a
outcome, whereas having a higher PaO2/FIO2 and poor outcome had significantly more transfusions

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 Table 3
Comparison of patient and treatment characteristics by primary indication (cardiac vs respiratory) for
patients experiencing poor and good outcomes after extracorporeal membrane oxygenation (ECMO)

Cardiac indication (n = 126)

Poor outcome (n = 99, 78.6%) Good outcome (n = 27, 21.4%)
Patient characteristic n No. (%) No. (%) P

Sex 126 .17

Male 61 (61.6) 21 (77.8)
Female 38 (38.4) 6 (22.2)
Race 126 .34
White 93 (93.9) 27 (100.0)
Other 6 (6.1) 0 (0.0)
n Mean (SD) n Mean (SD)

Age, years 126 99 55.10 (12.5) 27 48.33 (12.5) .01a

Weight, kg 126 99 85.22 (22.2) 27 88.39 (23.2) .52
Body mass indexb 125 98 29.01 (6.7) 27 28.87 (6.5) .92
Ejection fraction, % 117 92 35 (19) 25 25 (18) .03a
Charlson Comorbidity Index 123 97 4.04 (2.0) 26 3.77 (1.5) .52
Mechanical ventilator days, before ECMO 124 99 2.03 (2.0) 25 1.40 (0.6) .12
Murray Acute Lung Injury score 123 97 2.38 (1.0) 26 2.21 (1.0) .44
pH 114 91 7.26 (0.16) 23 7.27 (0.13) .86
PaO2/FIO2 ratio 112 89 171.46 (145.5) 23 207.63 (165.9) .17
Compliance, mL/cm H2O 105 83 25.31 (10.2) 22 25.71 (10.3) .87
Peak inspiratory pressure, cm H2O 107 85 31.23 (8.3) 22 33.27 (8.8) .33
Positive end-expiratory pressure, cm H2O 109 86 7.05 (4.1) 23 7.54 (3.6) .51
Tidal volume/kg, mL/kg 110 87 6.95 (2.1) 23 7.00 (2.0) .91
No. (%) No. (%)

Respiratory adjuncts, before ECMO, any 123 88 (89.8) 15 (60.0) .001a

Bagging 123 22 (22.4) 3 (12.0) .28
Nitric oxide 123 21 (21.4) 6 (24.0) .79
High-frequency oscillatory ventilation 123 1 (1.0) 0 (0.0) >.99
Prone positioning 123 0 (0.0) 0 (0.0) —
Neuromuscular blockade 123 74 (75.5) 14 (56.0) .08
Cardiovascular adjuncts, before ECMO, any 126 98 (99.0) 27 (100.0) >.99
Pressor 126 98 (99.0) 26 (96.3) .38
Inotrope 126 98 (99.0) 26 (96.3) .38
Intra-aortic balloon pump 126 67 (67.7) 17 (63.0) .82
Ventricular assist device 126 17 (17.2) 1 (3.7) .12
Cardiopulmonary resuscitation/defibrillation 126 45 (45.5) 12 (44.4) >.99
Treatment characteristic n Mean (SD) n Mean (SD)

ECMO hours 126 99 116.74 (125.8) 27 97.52 (72.5) .92

Transfusion total units 125 98 45.67 (44.1) 27 22.07 (20.1) .02a
Hospital length of stay, days 126 99 17.55 (22.5) 27 44.22 (28.8) <.001a

(46 units poor vs 22 good, P = .02) and a higher preva-
lence of central cannulation (70% poor vs 37% good,
P = .003). In both the cardiac and the respiratory
indication subgroups, patients with a good outcome
had longer hospital stays than did patients with a
poor outcome. In the cardiac indication subgroup,
significantly more patients who had a poor outcome
experienced any complication, including neurological
problems, renal failure, liver dysfunction, MSOF/shock,
and vascular issues (all P values < .05), whereas

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 Discussion
Respiratory indication (n = 86) This report describes the patient and treatment
Poor outcome (n = 43, 50%) Good outcome (n = 43, 50%) characteristics and outcome of a large cohort of
n No. (%) No. (%) P adult ECMO patients from a single center during 5
years and provides insight into what clinicians might
86 >.99 expect when providing care for ECMO patients. In
27 (62.8) 28 (65.1) this sample, 59% of ECMO patients had a cardiac
16 (37.2) 15 (34.9)
indication whereas 41% had a respiratory indica-
86 >.99
40 (93.0) 39 (90.7) tion for treatment. Overall only a little more than
3 (7.0) 4 (9.3) half of patients were successfully weaned from
n Mean (SD) n Mean (SD)
ECMO, but 33% had a good outcome and were
discharged alive. Nearly all patients needed adjunc-
86 43 48.44 (16.9) 43 46.81 (15.6) .64 tive cardiac and respiratory support therapies before
86 43 80.48 (26.1) 43 82.47 (21.2) .70 ECMO. The mean ECMO duration was 5.6 days,
86 43 26.63 (6.7) 43 27.82 (7.1) .43 and transfusion requirements were high.
73 39 55 (12) 34 51 (15) .26 Nearly all patients experienced some type of com-
84 41 2.98 (2.0) 43 3.40 (2.2) .37 plication while being treated with ECMO or within 2
86 43 6.12 (7.3) 43 2.81 (2.7) .01a weeks after being weaned off of ECMO. Mechanical
86 43 3.56 (0.4) 43 3.54 (0.5) .63 ECMO complications were rare and are not reported
83 43 7.23 (0.13) 40 7.27 (0.10) .23
here. In contrast to most other reports listing only
mechanical complications or limiting physiological
81 42 71.04 (470.6) 39 63.26 (23.6) .81
complications to the ECMO course, we included
78 39 19.15 (9.6) 39 25.04 (9.7) .008a
patients’ complications out to 2 weeks after ECMO
78 39 39.38 (6.9) 39 35.46 (7.7) .02a
completion in an effort to reflect the impact of ECMO
80 40 14.40 (4.0) 40 14.39 (5.3) .99 more accurately and describe the critical care needs
79 39 5.52 (2.0) 40 6.39 (2.2) .08 of this complex population of patients better.
No. (%) No. (%) We noted significant differences in outcome
85 41 (95.3) 42 (100.0) .49 between patients with a cardiac versus a respiratory
85 13 (30.2) 15 (35.7) .65
indication for ECMO. Patients treated with ECMO
for a respiratory indication had significantly better
85 31 (72.1) 22 (52.4) .08
outcomes (50% survived to discharge) than did
85 7 (16.3) 3 (7.1) .31
patients who had a cardiac indication (only 21%
85 1 (2.3) 4 (9.5) .20
survived to discharge) and were more likely to expe-
85 37 (86.0) 36 (85.7) >.99 rience better 1-year survival as well. This result is
86 42 (97.7) 37 (86.0) .11 consistent with findings from the Extracorporeal
86 42 (97.7) 37 (86.0) .11 Life Support Organization (ELSO) registry report,2
86 26 (60.5) 27 (62.8) >.99 which describes survival to discharge for adult res-
86 1 (2.3) 0 (0.0) >.99 piratory and cardiac indication patients as 53% and
86 1 (2.3) 0 (0.0) >.99 33%, respectively. Our findings also corroborate the
86 6 (14.0) 3 (7.0) .48 CESAR trial, a randomized, controlled trial of 180
n Mean (SD) n Mean (SD) patients with severe respiratory failure prospectively
randomized to conventional management or
86 43 168.00 (178.6) 43 167.00 (190.1) .71 referred to an ECMO center to be considered for
86 43 52.79 (86.3) 43 25.42 (24.0) .13 ECMO. In that trial, of 90 patients referred for
86 43 38.28 (50.1) 43 50.14 (33.1) .002a ECMO consideration, 68 received ECMO, of whom
Continued
63% survived to 6 months without disability (vs
47% of those receiving conventional management).4
In several other studies of ECMO for severe acute
significantly more patients in the good outcome group respiratory failure or ARDS, 49% to 66% of patients
experienced infection. In the respiratory indication sub- survived to hospital discharge1,3,6,7,23-25 and 55% to
group, significantly more patients with poor outcome 70% survived to ICU discharge.5,8
experienced neurological problems, renal failure, liver Our findings for survival after a cardiac indica-
dysfunction, MSOF/shock, and arrest (all P values < .05). tion for ECMO are also similar to those reported by

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 Table 3
Continued

Cardiac indication (n = 126)

Poor outcome (n = 99, 78.6%) Good outcome (n = 27, 21.4%)
Treatment characteristic n No. (%) No. (%) P

Mode, any venoarterial 126 99 (100.0) 27 (100.0) —

Cannulation, any central 126 69 (69.7) 10 (37.0) .003a
Complications, any 126 99 (100.0) 24 (88.9) .009a
Bleeding 126 66 (66.7) 16 (59.3) .50
Neurological problems 126 62 (62.6) 5 (18.5) <.001a
Renal failure, dialysis 126 67 (67.7) 11 (40.7) .01a
Liver dysfunction 126 49 (49.5) 6 (22.2) .02a
Multisystem organ failure/shock 126 73 (73.7) 3 (11.1) <.001a
Arrest 126 42 (42.4) 8 (29.6) .27
Vascular issues 126 50 (50.5) 6 (22.2) .02a
Infection 126 30 (30.3) 18 (66.7) .001a
Abbreviation: FIO2, fraction of inspired oxygen.
a Statistically significant.
b Calculated as the weight in kilograms divided by the height in meters squared.

Table 4 which comprised 38% of the subgroup, only 8%

Multivariate logistic regression of patient survived, whereas of our patients with cardiogenic
characteristics predictive of good outcome shock, comprising 35% of the subgroup, 31% sur-
for all 212 patients supported with extra- vived. Thus our high proportion of postcardiotomy
corporeal membrane oxygenation (ECMO)
patients may have skewed overall survival in this
95% CI subgroup downward.
Odds
Characteristic ratio Lower Upper P We also noted differences in survival in our
indication subgroups depending on the causes of
Primary indication: cardiac respiratory failure. ARDS patients had a 51% sur-
Age, years 0.939 0.893 0.987 .01a vival to discharge, as compared with 42% of our
Male sexb 2.133 0.617 7.378 .23
Charlson Comorbidity Index 0.973 0.744 1.274 .84
PGD lung transplant recipients. This result is com-
Ejection fraction 1.105 0.050 24.635 .95 parable to results in a prior report from our center
PaO2/FIO2 ratio 1.004 1.000 1.008 .03a in a smaller sample (33 patients; 16 lung transplant
Not using any respiratory adjuncts 8.982 2.078 38.823 .003a recipients with PGD and 9 with ARDS) with survival
before ECMOc to discharge of 39%26 and is corroborated in a more
Primary indication: respiratory recent report15 from our center on ECMO for adults
Age, years 0.991 0.960 1.024 .60 with PGD after lung transplant, who had a 30-day
Male sexb 0.667 0.226 1.966 .46
survival of 56%. Another center reported a 90-day
Charlson Comorbidity Index 1.207 0.947 1.538 .13
Mechanical ventilator days, before ECMO 0.851 0.737 0.984 .03a survival of 60% in 15 ECMO patients with PGD after
Peak inspiratory pressure, cm H2O 0.914 0.848 0.987 .02a lung transplant,16 whereas the ELSO registry reports
Tidal volume per kg, mL/kg 1.080 0.849 1.373 .53 that 42% of 151 adult and pediatric lung transplant
recipients with PGD survived to discharge.14
Abbreviation: FIO2, fraction of inspired oxygen.
a Statistically significant. A number of other factors have been associated
b Female is referent.
c Using any respiratory adjunct is referent.
with poor outcome in ECMO patients with respira-
tory failure. More days of mechanical ventilation
before ECMO has repeatedly been shown to corre-
the ELSO registry for this subgroup (33% survival),2 late with worse outcome. Pranikoff et al27 reported
whereas other reports1,10,11 on ECMO for cardiac fail- survival rates of 73% to 75% when patients had 4
ure describe survival ranging from 29% to 39%. days or less of mechanical ventilation, whereas sur-
Although our cardiac indication subgroup’s survival vival was only 20% to 25% when patients had 5 days
of 21% was lower than the survival rates in some or more of mechanical ventilation. In a number of
reports, this may reflect our distribution of causes other studies, researchers found that both greater
of the cardiac failure. Of postcardiotomy patients, age and more days of mechanical ventilation were

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 other centers between more transfusion and
Respiratory indication (n = 86) worse outcome in respiratory ECMO patients.6
Poor outcome (n = 43, 50%) Good outcome (n = 43, 50%) Our patients who had a poor outcome had
n No. (%) No. (%) P significantly higher percentages of nearly every
complication. Renal failure and bleeding com-
86 8 (18.6) 12 (27.9) .44 plications are widely reported by others, and our
86 8 (18.6) 5 (11.6) .55 renal failure prevalence is comparable, but our
86 42 (97.7) 37 (86.0) .11 prevalence for bleeding is higher than reported
86 22 (51.2) 19 (41.9) .52 by others.3,24 Our higher rate of complications as
86 24 (55.8) 8 (18.6) .001a compared with other centers may be partly
86 32 (74.4) 19 (44.2) .008a explained by our methods (we included compli-
86 19 (44.2) 5 (11.6) .001a
cations for the entire ECMO course and up to 2
weeks after ECMO), as well as the lack of com-
86 33 (76.7) 2 (4.7) <.001a
mon definitions for defining complications
86 12 (27.9) 2 (4.7) .007a
between various reports. Our higher infection
86 8 (18.6) 8 (18.6) >.99
rate in our patients with a good outcome most
86 26 (60.5) 29 (67.4) .65 likely reflects their longer hospital stay and the
fact that infection becomes more likely as the
course of care lengthens for survivors.

associated with worse outcome.3,6,24,28,29 In our sample,
mean age was significantly greater for patients who
had a poor outcome in the total sample and cardiac
subgroups, and age remained significantly associated
with outcome for the cardiac subgroup in the regres-
sion analysis. We found that days of mechanical venti-
lator support trended higher in patients with a poor
outcome (3 days vs 2 days), but was not significantly
different between outcome groups either in the total
sample or the cardiac subgroup. Notably, in our respi-
ratory subgroup, those with poor outcome had signifi-
cantly more days of mechanical ventilation before
ECMO than did the good outcome group, and in the
regression analysis, more days of mechanical ventila-
tion before ECMO was negatively associated with a
good outcome.
Our finding that the Murray ALI score for the total
sample was higher in the good outcome group is con-
trary to what we expected, as higher Murray scores (closer
to 4) reflect higher risk. However, the Murray score is
intended to stratify patients with ARDS and ALI, and it
may not have served as a reliable risk tool in our patients
with a variety of other indications for ECMO.
We noted higher percentages of patients with poor
outcome with the use of each cardiovascular adjunct
before ECMO, which most likely reflects that most patients
were in critically unstable condition when ECMO was
started. We also noted that more transfusions were asso-
ciated with poor outcome in the total sample and the
cardiac subgroup, but the transfusion needs were not
significantly different between patients with poor and
good outcomes in our respiratory indication subgroup.
This finding is in contrast to the association noted by
Limitations
This study had several limitations. Using a
sample from a single center’s ECMO experience
may limit the generalizability of the results. In
our retrospective review, data were collected from
electronic and paper medical records, which were
not designed for the purpose of data collection
and may not have yielded as rigorous a report of
variables as a prospective trial would have yielded.
Specifically, we may have underestimated com-
plications because we detected them via review
of patients’ charts and ordered therapies, a
method that may be subject to provider bias.
Finally, the inequality in the numbers of patients
in our cardiac and respiratory indication sub-
groups, and in the numbers of patients with poor
and good outcomes, might affect between-group
comparisons; equal numbers might have yielded
more robust findings. Nevertheless, our findings
provide valuable insight into the course of ther-
apy and outcome for a large clinical cohort.
Conclusion
ECMO is offered as a supportive therapy to
an expanding population of patients with acutely
life-threatening cardiac or respiratory failure.
Patients are at high risk for ECMO-related mor-
bidity. Clinicians may anticipate lower survival
rates for patients in whom ECMO is initiated for
a primary cardiac cause compared with patients
in whom ECMO is started because of respiratory
failure. Complications are experienced by most of
both cardiac and respiratory failure patients treated
with ECMO, and patients with poor outcomes

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 experienced more complications than did patients
with good outcomes, adding significant complexity
to the care of patients undergoing ECMO. Increas-
ing age was associated with poorer outcome in the
total sample and in patients with cardiac indications
for ECMO and may have implications for anticipa-
tory guidance. Knowledge of the anticipated course
of treatment, outcomes of ECMO therapy, common
complications, and patterns of care can provide cli-
nicians with valuable insight into the care and treat-
ment of ECMO patients.
ACKNOWLEDGMENTS
We thank Melissa Saul, MS, clinical data scientist in the
Department of Biomedical Informatics, University of
Pittsburgh, for data collection for comorbid conditions
and calculation of each patient’s Charlson Comorbidity
Index score.
FINANCIAL DISCLOSURES
None reported.
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 CNE Test Test ID A1423052: Discharge Outcome in Adults Treated with Extracorporeal Membrane Oxygenation
Learning objectives: 1. Describe the medical indications for the use of extracorporeal membrane oxygenation (ECMO). 2. Identify the complications
associated with ECMO. 3. Discuss the outcomes associated with ECMO.

1. Extracorporeal membrane oxygenation (ECMO) is a rescue therapy 9. Which one of the following patient conditions treated with ECMO was more likely
used to eliminate which one of the following? to have a good outcome?
a. Oxygen a. Acute respiratory distress syndrome
b. Nitrogen b. Cardiogenic shock
c. Carbon dioxide c. Primary graft dysfunction after transplant
d. Carbon monoxide d. Failure to wean from cardiopulmonary bypass following cardiac surgery

2. All of the following are indications for ECMO except? 10. Of patients who were treated with ECMO, the predominant cause of death was
a. Cardiogenic shock which one of the following?
b. Sepsis a. Multisystem organ failure
c. Acute respiratory distress syndrome b. Renal failure
d. Primary graft dysfunction after transplant c. Infection
d. Hemorrhage
3. All of the following were used to determine complications of ECMO
except? 11. In patients with a cardiac indication for ECMO, which one of the following was
a. Reviewing clinical and operative notes associated with a poor outcome?
b. ICD-9 admission codes a. Male gender
c. Provider interviews b. Increased age
d. Autopsy reports c. Race
d. Chronic illness
4. ECMO patients had an average left ventricular ejection fraction of
what percent? 12. Of patients treated with ECMO for a respiratory indication, what percentage
a. 20% c. 30% survived to discharge?
b. 25% d. 41% a. 20% c. 50%
b. 40% d. 70%
5. The mean number of blood products used during ECMO was?
a. 10 units c. 30 units 13. Which one of the following has repeatedly been shown to correlate with worse
b. 20 units d. 40 units outcome before the use of ECMO?
a. More days of mechanical ventilation
6. What percentage of patients who received ECMO experienced a b. Use of vasopressors
complication? c. Blood transfusions
a. More than 25% c. More than 75% d. Renal replacement therapy
b. More than 50% d. More than 95%
14. The authors found the prevalence of which one of the following in their center
7. Which one of the following was the most common complication to be higher than in other ECMO centers?
experienced with ECMO? a. Renal failure
a. Cardiac arrest b. Stroke
b. Limb ischemia c. Liver dysfunction
c. Renal failure requiring dialysis d. Bleeding
d. Myopathy
15. The average hospital length of stay for patients who had a good outcome after
8. Of the patients who were successfully weaned from ECMO, how many treatment with ECMO was?
lived to discharge? a. 23.82 days
a. 28% c. 57% b. 34.56 days
b. 33% d. 67% c. 47.86 days
d. 52.76 days

Test ID: A1423052Contact hours: 1.0; pharma 0.0 Form expires: September 1, 2017. Test Answers: Mark only one box for your answer to each question.
1. ❑ a 2. ❑ a 3. ❑ a 4. ❑ a 5. ❑ a 6. ❑ a 7. ❑ a 8. ❑ a 9. ❑ a 10. ❑ a 11. ❑ a 12. ❑ a 13. ❑ a 14. ❑ a 15. ❑ a
❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑b
❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑c
❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d ❑d
Fee: AACN members, $0; nonmembers, $10 Passing score: 12 correct (80%) Category: CERP A Test writer: Daniel N. Storzer, RN, MS, APRN, ACNPC, ACNP-BC, CNRN, CCRN, CCEMT-P
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