Routine CT scanning of patients retrieved to a tertiary centre on veno-venous extracorporeal membrane oxygenation: a retrospective risk benefit analysis

Abstract

Introduction:

Comprehensive clinical examination can be compromised in patients on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Adjunctive diagnostic imaging strategies range from bedside imaging only to routine computed tomography (CT). The risk-benefit of either approach remains to be evaluated. Patients retrieved to the Royal Brompton Hospital (RBH) on VV-ECMO routinely undergo admission CT imaging of head, chest, abdomen and pelvis.

This study aimed to identify how frequently changes in therapy or adverse events could be attributed to routine CT scanning.

Methods:

Demographic and clinical data were gathered retrospectively from patients retrieved to RBH on VV-ECMO (January 2014-2016). Scans were categorized as ‘routine’ or requested to clarify a specific clinical uncertainty. Clinical records were reviewed to identify attributable management changes and CT- related adverse events.

Seventy-two patients were retrieved on VV-ECMO (median age 44 years) and 65 scanned on admission (mean radiation dose 2344mGy-cm). Routine head CT head yielded novel clinical information in 11 patients, 10 of whom had unexpected intracranial haemorrhage and, subsequently, had their anticoagulation withheld. Routine thoracic CT identified unexpected positive findings in three patients (early fibrosis, pulmonary vasculitis, pneumomediastinum), eliciting management variation in one (steroid administration). Routine abdomen/pelvis CT identified new information in three patients (adrenal haemorrhage, hepatosteatosis, splenic infarction), changing the management in one (withholding anticoagulation).

Results:

CT scanning was not associated with consequential adverse events (e.g. accidental decannulation, gas entrainment into the circuit, hypoxia, hypotension). Median transfer/scan time was 78 minutes, requiring five ITU staff-members. In our cohort, a policy of routine head CT changed the management in 17% of patients; the yield from routine chest, abdomen and pelvis CT was modest. CT transfer was safe, but resource intensive.

Conclusion:

Prospective studies should evaluate whether routine CT impacts outcome.

Keywords

cardiopulmonary bypass management

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References

Brogan

Thiagarajan

Rycus

Bartlett

Bratton

. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 2009; 35: 2105–2114.

Peek

Mugford

Tiruvoipati

et al . Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351–1363.

Noah

Peek

Finney

et al . Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306: 1659–1668. PubMed PMID: 21976615.

Australia, New Zealand Extracorporeal Membrane Oxygenation Influenza investigators Davies

Jones

Bailey

et al . Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009; 302: 1888–1895.

Paden

Conrad

Rycus

Thiagarajan

Registry

. Extracorporeal Life Support Organization Registry Report 2012. ASAIO J 2013; 59: 202–210.

Organisation ELS. Guidelines for Adult Respiratory Failure. Available from: http://www.elso.org/Resources/Guidelines.aspx

Lidegran

Palmer

Jorulf

Linden

. CT in the evaluation of patients on ECMO due to acute respiratory failure. Pediatr Radiol 2002; 32: 567–574.

Foley

Pranikoff

Younger

et al . A review of 100 patients transported on extracorporeal life support. ASAIO J 2002; 48: 612–619.

Beckmann

Gillies

Berenholtz

Pronovost

. Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med 2004; 30: 1579–1585.

10.

Bramley

Barnes

Ashworth

et al . Incidence of intracranial haemorrhage in patients undergoing vv-ecmo; retrospective single centre review. J Cardiothorac Vasc Anesth 2015; 29: S55.

11.

Martucci

Lo Re

Arcadipane

. Neurological injuries and extracorporeal membrane oxygenation: the challenge of the new ECMO era. Neurological Sciences 2016; 37: 1133–1136.

12.

Lidegran

Mosskin

Ringertz

Frenckner

Linden

. Cranial CT for diagnosis of intracranial complications in adult and pediatric patients during ECMO: clinical benefits in diagnosis and treatment. Academ Radiol 2007; 14: 62–71.

13.

Jepson

Harvey

Entwisle

Peek

. Management benefits and safety of computed tomography in patients undergoing extracorporeal membrane oxygenation therapy: experience of a single centre. Clin Radiol 2010; 65: 881–886.

14.

Lidegran

Ringertz

Frenckner

Linden

. Chest and abdominal CT during extracorporeal membrane oxygenation: clinical benefits in diagnosis and treatment. Academ Radiol 2005; 12: 276–285.

15.

Aubron

Cheng

Pilcher

et al . Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care 2013; 17: R73.

16.

Mateen

Muralidharan

Shinohara

Parisi

Schears

Wijdicks

. Neurological injury in adults treated with extracorporeal membrane oxygenation. Arch Neurol 2011; 68: 1543–1549.

17.

Di Lorenzo

Martucci

Sciacca

Longo

Pilato

Arcadipane

. Dysfunction of mechanical mitral prosthesis at 33rd week of pregnancy: ECMO support as a complex strategy for the mother and the fetus. Perfusion 2016; 31: 611–613.

18.

Martucci

Panarello

Occhipinti

et al . Anticoagulation and Ttansfusions management in veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: assessment of factors associated with transfusion requirements and mortality. J Inten Care Med 2017: 885066617706339.

19.

Broman

Holzgraefe

Palmer

Frenckner

. The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation. Crit Care 2015; 19: 278.

20.

Bryner

Cooley

Copenhaver

et al . Two decades’ experience with interfacility transport on extracorporeal membrane oxygenation. Ann Thorac Surg 2014; 98: 1363–1370.

21.

Starck

Hasenclever

Falk

Wilhelm

. Interhospital transfer of seriously sick ARDS patients using veno-venous Extracorporeal Membrane Oxygenation (ECMO): concept of an ECMO transport team. Inter J Crit Ill Inj Sci 2013; 3: 46–50.

22.

Lambert

Grus

Balik

Fichtl

Kavan

Belohlavek

. Hemodynamic changes in patients with extracorporeal membrane oxygenation (ECMO) demonstrated by contrast-enhanced CT examinations - implications for image acquisition technique. Perfusion 2017; 32: 220–225.