Sarah Godfrey1, Aradhana Sahoo1, Joseph Sanchez2, Justin Fried3, Amirali Masoumi3, Daniel Brodie4, Hiroo Takayama5, Nir Uriel3, Koji Takeda5, Shunichi Nakagawa6. 1. Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. 2. Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. 3. Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA. 4. Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA. 5. Division of Cardiac, Vascular, and Thoracic Surgery, Columbia University Irving Medical Center, New York, New York, USA. 6. Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA; Adult Palliative Care Services, Columbia University Irving Medical Center, New York, New York, USA. Electronic address: sn2573@cumc.columbia.edu.
Abstract
CONTEXT: As the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases, decisions regarding withdrawal from VA-ECMO increase. OBJECTIVES: To evaluate the clinical characteristics of patients withdrawn from VA-ECMO and the role of palliative care consultation in the decision. METHODS: We retrospectively reviewed adult patients with cardiogenic shock requiring VA-ECMO at our institution, who were withdrawn from VA-ECMO between January 1, 2014 and May 31, 2019. The relationship between clinical characteristics and palliative care visits was assessed, and documented reasons for withdrawal were identified. RESULTS: Of 460 patients who received VA-ECMO, 91 deceased patients (19.8%) were included. Forty-two patients (44.8%) had a palliative care consultation. The median duration on VA-ECMO was 4.0 days (interquartile range 8.8), and it was significantly longer for patients with palliative care consultation than those without (8.8 days vs. 2.0 days, P < 0.001). Among those with palliative care consultation, those with early consultation (within three days) had significantly shorter duration of VA-ECMO compared with those with late consultation (7.6 days vs. 13.5 days, t = 2.022, P = 0.008). Twenty-two (24.2%) had evidence of brain injury, which was significantly associated with patient age, number of comorbidities, duration of VA-ECMO, number of life-sustaining therapies, and number of palliative care visits (Wilks lambda 0.8925, DF 5,121, P = 0.016). Presence of brain injury was associated with fewer palliative care visits (t = 2.82, P = 0.006). CONCLUSION: Shorter duration of VA-ECMO support and presence of brain injury were associated with fewer palliative care visits. Decisions around withdrawal of VA-ECMO support might be less complicated when patient's medical conditions deteriorate quickly or when neurological prognosis seems poor.
CONTEXT: As the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases, decisions regarding withdrawal from VA-ECMO increase. OBJECTIVES: To evaluate the clinical characteristics of patients withdrawn from VA-ECMO and the role of palliative care consultation in the decision. METHODS: We retrospectively reviewed adult patients with cardiogenic shock requiring VA-ECMO at our institution, who were withdrawn from VA-ECMO between January 1, 2014 and May 31, 2019. The relationship between clinical characteristics and palliative care visits was assessed, and documented reasons for withdrawal were identified. RESULTS: Of 460 patients who received VA-ECMO, 91 deceased patients (19.8%) were included. Forty-two patients (44.8%) had a palliative care consultation. The median duration on VA-ECMO was 4.0 days (interquartile range 8.8), and it was significantly longer for patients with palliative care consultation than those without (8.8 days vs. 2.0 days, P < 0.001). Among those with palliative care consultation, those with early consultation (within three days) had significantly shorter duration of VA-ECMO compared with those with late consultation (7.6 days vs. 13.5 days, t = 2.022, P = 0.008). Twenty-two (24.2%) had evidence of brain injury, which was significantly associated with patient age, number of comorbidities, duration of VA-ECMO, number of life-sustaining therapies, and number of palliative care visits (Wilks lambda 0.8925, DF 5,121, P = 0.016). Presence of brain injury was associated with fewer palliative care visits (t = 2.82, P = 0.006). CONCLUSION: Shorter duration of VA-ECMO support and presence of brain injury were associated with fewer palliative care visits. Decisions around withdrawal of VA-ECMO support might be less complicated when patient's medical conditions deteriorate quickly or when neurological prognosis seems poor.
Authors: Julia M Carlson; Eric W Etchill; Clare Angeli G Enriquez; Anna Peeler; Glenn J Whitman; Chun Woo Choi; Romergryko G Geocadin; Sung-Min Cho Journal: J Cardiothorac Vasc Anesth Date: 2021-05-04 Impact factor: 2.894