Extracorporeal Membrane Oxygenation for Septic Shock

Lars Falk, MD; Jan Hultman, MD, PhD; Lars Mikael Broman, MD, PhD

Disclosures

Crit Care Med. 2019;47(8):1097-1105. 

In This Article

Abstract and Introduction

Abstract

Objectives: Septic shock carries a high mortality risk. Studies have indicated that patients with septic shock may benefit from extracorporeal membrane oxygenation. In most studies, patients exhibited shock due to myocardial dysfunction rather than distributive/vasoplegic shock. One proposed theory is that venoarterial extracorporeal membrane oxygenation alleviates a failing myocardial function.

Design: Retrospective observational study.

Setting: Single-center, high-volume extracorporeal membrane oxygenation unit.

Patients: All patients treated for septic shock between 2012 and 2017 with an age greater than 18 years old, fulfilling septic shock criteria according to "Sepsis-3" at acceptance for extracorporeal membrane oxygenation, presence of cardiocirculatory failure requiring a support equivalent to a Vasoactive Inotropic Score greater than 50 to reach a mean arterial pressure greater than 65 mm Hg despite adequate fluid resuscitation, were included.

Interventions: None.

Measurements and Main Results: Thirty-seven patients, mean age 54.7 years old, were included. Median Simplified Acute Physiology Score-3 score was 86 and Sequential Organ Failure Assessment 16. Twenty-seven patients were submitted to venoarterial and 10 patients to venovenous extracorporeal membrane oxygenation. Hospital survival was 90% for septic shock with left ventricular failure and 64.7% in patients with distributive shock. At long-term follow-up at 46.1 months, total survival was 59.5%. Commencement of venovenous extracorporeal membrane oxygenation and more organ failures at admission showed a less favorable outcome in terms of hospital and long-term survival.

Conclusions: The current results add not only to the growing evidence of the benefit of venoarterial extracorporeal membrane oxygenation for septic cardiomyopathy but also indicate improved hospital survival in distributive septic shock.

Introduction

Septic shock is known to have a high mortality rate and carries the highest risk of death in intensive care.[1] Albeit the increasing number of extracorporeal membrane oxygenation (ECMO) treatments, ECMO is not considered a standard treatment for adult patients with septic shock[2,3] as opposed to the pediatric and neonatal populations.[3–6] Even though ECMO has gained increased acceptance for treatment of adult severe respiratory failure, the controversy remains concerning its usefulness in septic shock.[2,7] During the last years, several publications question this standpoint[8–11] and indications emerge that ECMO may be performed with mortality rates comparable to or better than conventional treatment.[12] Bréchot et al[8] reported a 70% survival rate and low post-ECMO mortality compared with a reference cohort. However, others have reported worse outcome especially in combination with extracorporeal cardiopulmonary resuscitation (ECPR).[10,11]

This retrospective study was undertaken to describe a septic shock population with a combination of acute respiratory distress syndrome and cytotoxic cardiac failure or distributive shock submitted to ECMO treatment at a high-volume ECMO center.

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