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22.11.2022 | Original

Impact of BMI on outcomes in respiratory ECMO: an ELSO registry study

verfasst von: Marijke Peetermans, Ipek Guler, Philippe Meersseman, Alexander Wilmer, Joost Wauters, Bart Meyns, Alexander P. J. Vlaar, Alain Combes, Greet Hermans

Erschienen in: Intensive Care Medicine | Ausgabe 1/2023

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Abstract

Purpose

The impact of body mass index (BMI) on outcomes in respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) has been poorly described. We aimed to assess: (i) whether adults with class II obesity or more (BMI ≥ 35 kg/m²) have worse outcomes than lean counterparts, (ii) the form of the relationship between BMI and outcomes, (iii) whether a cutoff marking futility can be identified.

Methods

A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry from 1/1/2010 to 31/12/2020 was conducted. Impact of BMI ≥ 35 kg/m² was assessed with propensity-score (PS) matching, inverse propensity-score weighted (IPSW) and multivariable models (MV), adjusting for a priori identified confounders. Primary outcome was in-hospital mortality. The form of the relationship between BMI and outcomes was studied with generalized additive models. Outcomes across World Health Organisation (WHO)-defined BMI categories were compared.

Results

Among 18,529 patients, BMI ≥ 35 kg/m² was consistently associated with reduced in-hospital mortality [PS-matched: OR: 0.878(95%CI 0.798–0.966), p = 0.008; IPSW: OR: 0.899(95%CI 0.827–0.979), p = 0.014; MV: OR: 0.900(95%CI 0.834–0.971), p = 0.007] and shorter hospital length of stays. In patients with BMI ≥ 35 kg/m², cardiovascular (17.3% versus 15.3%), renal (37% versus 30%) and device-related complications (25.7% versus 20.6%) increased, whereas pulmonary complications decreased (7.6% versus 9.3%). These findings were independent of confounders throughout PS-matched, IPSW and MV models. The relationship between BMI and outcomes was non-linear and no cutoff for futility was identified.

Conclusion

Patients with obesity class II or more treated with ECMO for respiratory failure have lower mortality risk and shorter stays, despite increased cardiovascular, device-related, and renal complications. No upper limit of BMI indicating futility of ECMO treatment could be identified. BMI as single parameter should not be a contra-indication for respiratory ECMO.

Nur mit Berechtigung zugänglich

Schetz M, De Jong A, Deane AM, Druml W, Hemelaar P, Pelosi P, Pickkers P, Reintam-Blaser A, Roberts J et al (2019) Obesity in the critically ill: a narrative review. Intensive Care Med 45:757–769. https://doi.org/10.1007/s00134-019-05594-1CrossRef

Collaborators GBDO, Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, Lee A, Marczak L, Mokdad AH et al (2017) Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 377:13–27. https://doi.org/10.1056/NEJMoa1614362CrossRef

Anderson MR, Shashaty MGS (2021) Impact of obesity in critical illness. Chest 160:2135–2145. https://doi.org/10.1016/j.chest.2021.08.001CrossRef

Gong MN, Bajwa EK, Thompson BT, Christiani DC (2010) Body mass index is associated with the development of acute respiratory distress syndrome. Thorax 65:44–50. https://doi.org/10.1136/thx.2009.117572CrossRef

Combes A, Hajage D, Capellier G, Demoule A, Lavoue S, Guervilly C, Da Silva D, Zafrani L, Tirot P et al (2018) Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 378:1965–1975. https://doi.org/10.1056/NEJMoa1800385CrossRef

Brodie D, Slutsky AS, Combes A (2019) Extracorporeal life support for adults with respiratory failure and related indications: a review. JAMA 322:557–568. https://doi.org/10.1001/jama.2019.9302CrossRef

Hui DS, Joynt GM, Wong KT, Gomersall CD, Li TS, Antonio G, Ko FW, Chan MC, Chan DP et al (2005) Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors. Thorax 60:401–409. https://doi.org/10.1136/thx.2004.030205CrossRef

Swol J, Buchwald D, Strauch JT, Schildhauer TA, Ull C (2017) Effect of body mass index on the outcome of surgical patients receiving extracorporeal devices (VV ECMO, pECLA) for respiratory failure. Int J Artif Organs. https://doi.org/10.5301/ijao.5000572CrossRef

Merritt-Genore H, Lyden E, Ryan T, Kwapnoski Z (2020) The effect of patient obesity on extracorporeal membrane oxygenator outcomes and ventilator dependency. J Card Surg 35:1283–1286. https://doi.org/10.1111/jocs.14579CrossRef

10.

Alvarez NH, O’Malley TJ, Abai B, Salvatore DM, DiMuzio PJ, Hirose H (2021) Complications of peripheral cannulation site in obese patients on adult extracorporeal membrane oxygenation. ASAIO J 67:1294–1300. https://doi.org/10.1097/MAT.0000000000001507CrossRef

11.

Kon ZN, Dahi S, Evans CF, Byrnes KA, Bittle GJ, Wehman B, Rector RP, McCormick BM, Herr DL et al (2015) Class III obesity is not a contraindication to venovenous extracorporeal membrane oxygenation support. Ann Thorac Surg 100:1855–1860. https://doi.org/10.1016/j.athoracsur.2015.05.072CrossRef

12.

Galvagno SM Jr, Pelekhaty S, Cornachione CR, Deatrick KB, Mazzeffi MA, Scalea TM, Menaker J (2020) Does weight matter? Outcomes in adult patients on venovenous extracorporeal membrane oxygenation when stratified by obesity class. Anesth Analg 131:754–761. https://doi.org/10.1213/ANE.0000000000004454CrossRef

13.

Cho WH, Oh JY, Yeo HJ, Han J, Kim J, Hong SB, Chung CR, Park SH, Park SY et al (2018) Obesity survival paradox in pneumonia supported with extracorporeal membrane oxygenation: analysis of the national registry. J Crit Care 48:453–457. https://doi.org/10.1016/j.jcrc.2018.08.003CrossRef

14.

Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Terenzi P, Cozzolino M, Bernardo P, Peris A (2017) Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation. J Artif Organs 20:50–56. https://doi.org/10.1007/s10047-016-0931-8CrossRef

15.

Daviet F, Guilloux P, Hraiech S, Tonon D, Velly L, Bourenne J, Porto A, Gragueb-Chatti I, Bobot M et al (2021) Impact of obesity on survival in COVID-19 ARDS patients receiving ECMO: results from an ambispective observational cohort. Ann Intensive Care 11:157. https://doi.org/10.1186/s13613-021-00943-0CrossRef

16.

Trejnowska E, Drobinski D, Knapik P, Wajda-Pokrontka M, Szuldrzynski K, Staromlynski J, Nowak W, Urlik M, Ochman M et al (2022) Extracorporeal membrane oxygenation for severe COVID-19-associated acute respiratory distress syndrome in Poland: a multicenter cohort study. Crit Care 26:97. https://doi.org/10.1186/s13054-022-03959-5CrossRef

17.

Diaz RA, Graf J, Zambrano JM, Ruiz C, Espinoza JA, Bravo SI, Salazar PA, Bahamondes JC, Castillo LB et al (2021) Extracorporeal membrane oxygenation for COVID-19-associated severe acute respiratory distress syndrome in Chile: a nationwide incidence and cohort study. Am J Respir Crit Care Med 204:34–43. https://doi.org/10.1164/rccm.202011-4166OCCrossRef

18.

Al-Soufi S, Buscher H, Nguyen ND, Rycus P, Nair P (2013) Lack of association between body weight and mortality in patients on veno-venous extracorporeal membrane oxygenation. Intensive Care Med 39:1995–2002. https://doi.org/10.1007/s00134-013-3028-3CrossRef

19.

Verkerk BS, Dzierba AL, Muir J, Der-Nigoghossian C, Brodie D, Bacchetta M, Rietdijk W, Bakker J (2020) Opioid and benzodiazepine requirements in obese adult patients receiving extracorporeal membrane oxygenation. Ann Pharmacother 54:144–150. https://doi.org/10.1177/1060028019872940CrossRef

20.

Keyser A, Philipp A, Zeman F, Lubnow M, Lunz D, Zimmermann M, Schmid C (2020) Percutaneous cannulation for extracorporeal life support in severely and morbidly obese patients. J Intensive Care Med 35:919–926. https://doi.org/10.1177/0885066618801547CrossRef

21.

Zakhary B, Oppenheimer BW (2018) ECMO for all? Challenging traditional ECMO contraindications. J Crit Care 48:451–452. https://doi.org/10.1016/j.jcrc.2018.09.020CrossRef

22.

Shekar K, Badulak J, Peek G, Boeken U, Dalton HJ, Arora L, Zakhary B, Ramanathan K, Starr J et al (2020) Extracorporeal life support organization coronavirus disease 2019 interim guidelines: a consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers. ASAIO J 66:707–721. https://doi.org/10.1097/MAT.0000000000001193CrossRef

23.

https://www.elso.org/Registry.aspx. (2022). Accessed 20 Sep 2022

24.

https://www.elso.org/Registry/DataDefinitions,Forms,Instructions.aspx. (2022). Accessed 20 Sep 2022

25.

Lebel A, Subramanian SV, Hamel D, Gagnon P, Razak F (2018) Population-level trends in the distribution of body mass index in Canada, 2000–2014. Can J Public Health 109:539–548. https://doi.org/10.17269/s41997-018-0060-7CrossRef

26.

Lederer DJ, Bell SC, Branson RD, Chalmers JD, Marshall R, Maslove DM, Ost DE, Punjabi NM, Schatz M et al (2019) Control of confounding and reporting of results in causal inference studies. guidance for authors from editors of respiratory, sleep, and critical care journals. Ann Am Thorac Soc 16:22–28. https://doi.org/10.1513/AnnalsATS.201808-564PSCrossRef

27.

Schmidt M, Bailey M, Sheldrake J, Hodgson C, Aubron C, Rycus PT, Scheinkestel C, Cooper DJ, Brodie D et al (2014) Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med 189:1374–1382. https://doi.org/10.1164/rccm.201311-2023OCCrossRef

28.

Nunez JI, Gosling AF, O’Gara B, Kennedy KF, Rycus P, Abrams D, Brodie D, Shaefi S, Garan AR et al (2022) Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis. Intensive Care Med 48:213–224. https://doi.org/10.1007/s00134-021-06593-xCrossRef

29.

McCaffrey DF, Griffin BA, Almirall D, Slaughter ME, Ramchand R, Burgette LF (2013) A tutorial on propensity score estimation for multiple treatments using generalized boosted models. Stat Med 32:3388–3414. https://doi.org/10.1002/sim.5753CrossRef

30.

Thomas L, Li F, Pencina M (2020) Using propensity score methods to create target populations in observational clinical research. JAMA 323:466–467. https://doi.org/10.1001/jama.2019.21558CrossRef

31.

Chesnaye NC, Stel VS, Tripepi G, Dekker FW, Fu EL, Zoccali C, Jager KJ (2022) An introduction to inverse probability of treatment weighting in observational research. Clin Kidney J 15:14–20. https://doi.org/10.1093/ckj/sfab158CrossRef

32.

Austin PC (2009) Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med 28:3083–3107. https://doi.org/10.1002/sim.3697CrossRef

33.

Donders AR, van der Heijden GJ, Stijnen T, Moons KG (2006) Review: a gentle introduction to imputation of missing values. J Clin Epidemiol 59:1087–1091. https://doi.org/10.1016/j.jclinepi.2006.01.014CrossRef

34.

Austin PC, White IR, Lee DS, van Buuren S (2021) Missing data in clinical research: a tutorial on multiple imputation. Can J Cardiol 37:1322–1331. https://doi.org/10.1016/j.cjca.2020.11.010CrossRef

35.

Chiu LC, Lin SW, Chuang LP, Li HH, Liu PH, Tsai FC, Chang CH, Hung CY, Lee CS et al (2021) Mechanical power during extracorporeal membrane oxygenation and hospital mortality in patients with acute respiratory distress syndrome. Crit Care 25:13. https://doi.org/10.1186/s13054-020-03428-xCrossRef

36.

Zaidi SAA, Saleem K (2021) Obesity as a risk factor for failure to wean from ECMO: a systematic review and meta-analysis. Can Respir J 2021:9967357. https://doi.org/10.1155/2021/9967357CrossRef

37.

Christian-Miller N, Hadaya J, Nakhla M, Sanaiha Y, Madrigal J, Emami S, Cale M, Sareh S, Benharash P (2020) The impact of obesity on outcomes in patients receiving extracorporeal life support. Artif Organs 44:1184–1191. https://doi.org/10.1111/aor.13752CrossRef

38.

Kunavarapu C, Yeramaneni S, Melo J, Sterling RK, Huskey LC, Sears L, Burch C, Rodriguez SM, Habib PJ et al (2021) Clinical outcomes of severe COVID-19 patients receiving early VV-ECMO and the impact of pre-ECMO ventilator use. Int J Artif Organs 44:861–867. https://doi.org/10.1177/03913988211047604CrossRef

39.

Sakr Y, Alhussami I, Nanchal R, Wunderink RG, Pellis T, Wittebole X, Martin-Loeches I, Francois B, Leone M et al (2015) Being overweight is associated with greater survival in ICU patients: results from the intensive care over nations audit. Crit Care Med 43:2623–2632. https://doi.org/10.1097/CCM.0000000000001310CrossRef

40.

Kooistra EJ, Brinkman S, van der Voort PHJ, de Keizer NF, Dongelmans DA, Kox M, Pickkers P (2022) Body mass index and mortality in coronavirus disease 2019 and other diseases: a cohort study in 35,506 ICU patients. Crit Care Med 50:e1–e10. https://doi.org/10.1097/CCM.0000000000005216CrossRef

41.

Ni YN, Luo J, Yu H, Wang YW, Hu YH, Liu D, Liang BM, Liang ZA (2017) Can body mass index predict clinical outcomes for patients with acute lung injury/acute respiratory distress syndrome? A meta-analysis. Crit Care 21:36. https://doi.org/10.1186/s13054-017-1615-3CrossRef

42.

Grieco DL, Anzellotti GM, Russo A, Bongiovanni F, Costantini B, D’Indinosante M, Varone F, Cavallaro F, Tortorella L et al (2019) Airway closure during surgical pneumoperitoneum in obese patients. Anesthesiology 131:58–73. https://doi.org/10.1097/ALN.0000000000002662CrossRef

43.

Lazoura O, Parthipun AA, Roberton BJ, Downey K, Finney S, Padley S (2012) Acute respiratory distress syndrome related to influenza A H1N1 infection: correlation of pulmonary computed tomography findings to extracorporeal membrane oxygenation treatment and clinical outcome. J Crit Care 27:602–608. https://doi.org/10.1016/j.jcrc.2012.04.009CrossRef

44.

Vyas V, Lambiase P (2019) Obesity and atrial fibrillation: epidemiology, pathophysiology and novel therapeutic opportunities. Arrhythm Electrophysiol Rev 8:28–36. https://doi.org/10.15420/aer.2018.76.2CrossRef

45.

Sabaz MS, Asar S, Sertcakacilar G, Sabaz N, Cukurova Z, Hergunsel GO (2021) The effect of body mass index on the development of acute kidney injury and mortality in intensive care unit: is obesity paradox valid? Ren Fail 43:543–555. https://doi.org/10.1080/0886022X.2021.1901738CrossRef

46.

Gameiro J, Goncalves M, Pereira M, Rodrigues N, Godinho I, Neves M, Gouveia J, Silva ZCE, Jorge S et al (2018) Obesity, acute kidney injury and mortality in patients with sepsis: a cohort analysis. Ren Fail 40:120–126. https://doi.org/10.1080/0886022X.2018.1430588CrossRef

47.

Akinnusi ME, Pineda LA, El Solh AA (2008) Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med 36:151–158. https://doi.org/10.1097/01.CCM.0000297885.60037.6ECrossRef

48.

Sakr Y, Madl C, Filipescu D, Moreno R, Groeneveld J, Artigas A, Reinhart K, Vincent JL (2008) Obesity is associated with increased morbidity but not mortality in critically ill patients. Intensive Care Med 34:1999–2009. https://doi.org/10.1007/s00134-008-1243-0CrossRef

Titel: Impact of BMI on outcomes in respiratory ECMO: an ELSO registry study
verfasst von: Marijke Peetermans
Ipek Guler
Philippe Meersseman
Alexander Wilmer
Joost Wauters
Bart Meyns
Alexander P. J. Vlaar
Alain Combes
Greet Hermans
Publikationsdatum: 22.11.2022
Verlag: Springer Berlin Heidelberg
Erschienen in: Intensive Care Medicine / Ausgabe 1/2023
Print ISSN: 0342-4642
Elektronische ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-022-06926-4

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Impact of BMI on outcomes in respiratory ECMO: an ELSO registry study