Clinical PotpourriEarly fluid resuscitation and volume therapy in venoarterial extracorporeal membrane oxygenation
Introduction
There are several indications for venoarterial extracorporeal membrane oxygenation (VA-ECMO) [1], [2], [3], [4] including shock with low cardiac output [4] or patients after cardiopulmonary resuscitation [3]. Venous drainage of the VA-ECMO is dependent on sufficient supply of blood drawn from the large veins, typically the vena cava [5]. Due to an endothelial cell damage, a sepsis like syndrome is frequent in diseases like cardiogenic shock and the post resuscitation syndrome [6], [7]. As part of a sepsis like syndrome, capillary leakage can induce an intravascular hypovolemia. These facts might trigger a liberal intravenous fluid therapy to VA-ECMO patients. While a more liberal fluid therapy might be lifesaving in the initial phase of sepsis, several studies suggest adverse outcome associated with excessive fluid balance during the intensive care unit stay [8], [9], [10]. In a targeted temperature study of patients after out of hospital cardiac arrest, high intravenous fluid therapy early after return of spontaneous circulation was associated with more rearrests and increased pulmonary edema [11]. This might be less relevant for prognosis in case of extracorporeal therapy if organ perfusion and oxygenation can be insured by sufficient VA-ECMO blood flow. We therefore analyzed all VA-ECMO patients treated at our institution in order to evaluate fluid balance and volume therapy in respect of outcome focusing on the early time period after implantation.
Section snippets
Methods
We report retrospective data of a single center registry of patients on VA-ECMO. All patients presented at the Heart Center Freiburg University between October 2010 and November 2015. Data derived from the registry was blinded to patient identity and covered by an ethics approval (EK-Freiburg 151/14). For data analysis t-test, ANOVA, χ2-test or Mantel-Cox were employed as applicable and a P ≤ .05 was considered statistically significant. All values are given as mean ± SEM if not otherwise
Studied population
A total of 195 patients were included in this registry. Medium age at time of VA-ECMO implantation was 58.2 ± 1.1 years and a total of 71.8% of all patients were male. Most of the patients treated were either after in-hospital our out-of-hospital cardiac arrest (78 and 71 respectively) while 42 patients received the VA-ECMO for profound shock without preceding cardiopulmonary resuscitation. The average time on VA-ECMO therapy was 65.2 ± 4.6 hours in all patients while time on mechanical
Discussion
There is ample evidence in literature that fluid accumulation and positive balance after the initial phase of fluid resuscitation is associated with poorer outcomes [7], [8], [10], [13], [14]. Schmidt et al previously reported in a mixed collective of veno-arterial and veno-venous ECMO patients that survivors had a lower fluid balance when compared to non-survivors [15]. The published data on fluid balance in ECMO patients however only evaluated 24 hour time points and included only patients
Conclusion
Patients after VA-ECMO implantation in our registry received high volume therapy. Survivors had a significantly lower net balance when compared to non-survivors detectable consistently and as early as 3 hours after VA-ECMO implantation. Since higher fluid balance was linked to adverse outcomes reliably and especially 3 hours post-implantation, we found no evidence to support a liberal fluid therapy in VA-ECMO patients. This retrospective study cannot clarify if a lower fluid balance might be
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