Prone Positioning During Veno-Venous Or Veno-Arterial Extracorporeal Membrane Oxygenation:  Feasibility And Complications After Cardiothoracic Surgery

doi:10.21203/rs.3.rs-1422297/v1

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Prone Positioning During Veno-Venous Or Veno-Arterial Extracorporeal Membrane Oxygenation: Feasibility And Complications After Cardiothoracic Surgery

https://doi.org/10.21203/rs.3.rs-1422297/v1

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Extracorporeal membrane oxygenation (ECMO) is a standard treatment for refractory hypoxaemia (veno-venous ECMO, VV-ECMO) and cardiogenic shock (veno-arterial ECMO, VA-ECMO). Severe hypoxaemia may persist despite ECMO. Prone positioning (PP) can improve outcomes of acute respiratory distress syndrome (ARDS)(1,2). However, few data exist on PP in hypoxaemic patients receiving VV-ECMO or VA-ECMO, particularly after cardio-thoracic surgery. Here, we evaluated oxygenation and complications seen with PP during ECMO.

Authors’ contributions

TG, QC, and FS conceived and designed the study, supervised data collection , and validated the data.

TG and QC collected the data.

TG, QC, JT, AB, and FS interpreted the data, wrote the report, and approved the final version of the report.

Guarantor statement: T. Genty is the guarantor of the content of the manuscript including the data and data analysis.

Competing Interests and Funding

Financial/nonfinancial disclosures: Support was provided solely from institutional and/or departmental sources. None of the authors has any conflicts of interest to disclose.

Funding: This work was funded solely by institutional and/or departmental sources.

Availability of data and materials

The dataset used and/or analysed during the current study is available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The need for informed consent from individual patients was waived, in compliance with French law on retrospective observational healthcare studies of anonymised data.

Consent for publication

Not applicable

1. Guérin C, Reignier J, Richard J-C, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159‑68.

2. Franchineau G, Bréchot N, Hekimian G, Lebreton G, Bourcier S, Demondion P, et al. Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO. Ann Intensive Care. 2020;10:12.

3. Bachmann KF, Haenggi M, Jakob SM, Takala J, Gattinoni L, Berger D. Gas exchange calculation may estimate changes in pulmonary blood flow during veno-arterial extracorporeal membrane oxygenation in a porcine model. Am J Physiol Lung Cell Mol Physiol. 2020;318:L1211‑21.

4. Lai C, Adda I, Teboul J-L, Persichini R, Gavelli F, Guérin L, et al. Effects of prone positioning on venous return in patients with acute respiratory distress syndrome. Crit Care Med. 2021;49:781‑9.

5. Guervilly C, Prud’homme E, Pauly V, Bourenne J, Hraiech S, Daviet F, et al. Prone positioning and extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: time for a randomized trial? Intensive Care Med. 2019;45:1040‑2.

6. Giani M, Martucci G, Madotto F, Belliato M, Fanelli V, Garofalo E, et al. Prone positioning during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome. A multicenter cohort study and propensity-matched analysis. Ann Am Thorac Soc. 2021;18:495‑501.

Table. Characteristics and outcomes of the 34 patients managed with prone positioning during extracorporeal membrane oxygenation

Males/Females, n	25/9
Age, years, mean±SD	50.8±16.3
BMI, kg/m², mean±SD	29.2±6.3
SAPSII, mean±SD	38.0±11.8
Reason for ICU admission, n
Thoracic surgery, n=22	Pulmonary endarterectomy n=11
	Lung transplantation, n=7
	Lobectomy, n=1
	Tracheal resection, n=1
	ARDS after lung gunshot wound, n=1
	Pleural/pulmonary abscess, n=1
Heart surgery, n=3	Heart transplantation, n=1
	Bentall procedure, n=1
	Aortic valve replacement, n=1
Medical reasons, n=9	ARDS due to COVID-19, n=7
	Cardiogenic shock, n=2
Type of incision^a, n
Sternotomy	15
Bi-thoracotomy	4
Clamshell incision	3
Thoracotomy	1
Thoracoscopy	1
Other	2
Reason for ECMO^b
VV-ECMO (n=25)	Hypoxaemia due to ARDS/PGD, n=25
VA-ECMO (n=8) or VAV-ECMO (n=1)	Cardiogenic shock, n=5 Residual PH, n=4
Complications during PP^c
- Circulatory arrest during an ECMO-VA membrane change - ECMO pump thrombosis related to HIT - Cardiac tamponade - Reperfusion-cannula displacement - Tracheostomy decannulation - Sternal wound infection	1 1 1 1 1 1
PP session characteristics^d
Number of PPs before ECMO implantation, median [IQR]	0 [0–1]
Number of PPs during ECMO,median/patient [IQR] -all patients - VV-ECMO - VA-ECMO	2 [1–2.8] 2 [1–3] 2 [1–2]
PP session duration, hours, mean±SD	18.0±4.2
Reason for PP	Refractory hypoxaemia n=19 Persistent hypoxaemia n=15
Ventilation parameters^e
Patients with volume-controlled ventilation, n (%)	22 (65)
Patients with pressure-controlled ventilation, n (%)	12 (35)
Tidal volume, mL/kg predicted body weight, mean±SD	4.5±1.7
PEEP, cm H₂O, median [IQR]	10 [10–15]
Respiratory rate, breaths/min, median [IQR]	20 [18–28]
ECMO^f
Blood flow, L/min, mean±SD all patients VV-ECMO VA-ECMO	4.5±1.7 4.6±1.8 3.7±1.1
Gas flow, L/min, mean±SD all patients VV-ECMO VA-ECMO	5.6±2.4 6.0±2.4 3.9±1.7
FiO₂ _ECMO, %, mean±SD all patients VV-ECMO VA-ECMO	95±12 95±12 95±13
Days on ECMO, median [IQR] all patients VV-ECMO VA-ECMO	15 [12–24] 15 [12–27] 15 [10–17]
Days from last PP to end of ECMO, median [IQR] all patients VV-ECMO VA-ECMO	5.5 [3.3–9.5] 5 [3–8] 8.5 [4.8–10.8]
Days from ECMO to first PP, median [IQR] all patients VV-ECMO VA-ECMO	7 [4–10] 6 [4–10] 7 [4–8]
Days from ICU admission to ECMO, median [IQR] all patients VV-ECMO VA-ECMO	2 [0–6.8] 3 [0–7] 0 [0–1]
Outcome
ICU stay (days), median [IQR] all patients VV-ECMO VA-ECMO	31.5 [21–49] 32 [26–56] 19 [13–42]
Weaning off ECMO within 3 days after last PP, n (%) all patients VV-ECMO VA-ECMO	7/34 (21) 6/25 (24) 1/9 (11)
Death, n (%) all patients VV-ECMO VA-ECMO	9/34 (26) 5/25 (20) 4/9 (44)

ECMO: extracorporeal membrane oxygenation; FiO₂: fraction of inspired oxygen; PEEP: positive end-expiratory pressure; BMI: body mass index; SAPS II: Simplified Acute Physiology Score version II; ICU: intensive care unit; ARDS: acute respiratory distress syndrome; PGD: primary graft dysfunction; PP: prone positioning; PH: pulmonary hypertension, HIT: heparin-induced thrombocytopenia; IQR: interquartile range; SD: standard deviation

a: 26 patients had a surgical incision. Among them, 25 underwent cardio-thoracic surgery and one had a caesarean section. Patients managed with PP did not experience delayed wound healing or wound pressure sores. Subxiphoid drains but not laterothoracic drains were removed before PP sessions.

b: Among the five patients with cardiogenic shock, three had had heart surgery and two had shock due to medical reasons. The four patients with residual pulmonary hypertension had had pulmonary endarterectomy. No lung transplant recipients were on VA-ECMO at the time of PP.

c: One patient receiving peripheral VA-ECMO experienced a sternal infection, which was diagnosed before PP was started.

d: PP was performed according to a written standard procedure. All complications were reviewed after the session by the team. PP was expected to at least 16 hours. However, the session could be shortened in the event of complications. At least seven staff members were required for turnings. An intensivist, a perfusionist, and a physiotherapist experienced in the management of PP were always among these seven staff membrers. One person focussed only on managing the head (intubation tube, central line, jugular cannula if any, nasogastric tube, and head support points) and another on managing the ECMO cannulas. The PP sessions were repeated according to the risk/ benefit ratio, i.e., to the balance between complications (mainly pressure sores) and improved oxygenation.

e: Maximum plateau pressure (cmH₂O) was 30 cmH₂O for both pressure-controlled and volume-controlled ventilation.

f: Patients receiving VA- or VV-ECMO were managed according to Extra-corporeal Life Support Organisation recommendations. ECMO was maintained until the respiratory and/or haemodynamic parameters improved. Weaning was conducted according to a local protocol. Briefly, VV-ECMO was explanted if the respiratory status did not deteriorate after 24 hours of gas clamping. For VA-ECMO, a weaning test was performed with evaluation of haemodynamic and echocardiography parameters under 0.5 L/min of ECMO flow. Anticoagulation was with heparin to achieve an activated partial thromboplastin time equal to 1.5 to 2.0 times the control value. In the event of a bleeding complication, heparin was temporarily stopped. If the bleeding persisted, the ECMO oxygenator was changed.

Atrio-septostomy was to be performed to unload the left ventricle if needed. However, none of our patients required this procedure.

No competing interests reported.

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