Characterization of patients transported with extracorporeal respiratory and/or cardiovascular support in the State of São Paulo, Brazil

Li, Ho Yeh; Mendes, Pedro Vitale; Melro, Livia Maria Garcia; Joelsons, Daniel; Besen, Bruno Adler Maccagnan Pinheiro; Costa, Eduardo Leite Viera; Hirota, Adriana Sayuri; Barbosa, Edzangela Vasconcelos Santos; Foronda, Flavia Krepel; Azevedo, Luciano Cesar Pontes; Romano, Thiago Gomes; Park, Marcelo

doi:10.5935/0103-507X.20180052

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ORIGINAL ARTICLE • Rev. bras. ter. intensiva 30 (3) • Jul-Sept 2018 • https://doi.org/10.5935/0103-507X.20180052 copy

Characterization of patients transported with extracorporeal respiratory and/or cardiovascular support in the State of São Paulo, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To characterize the transport of severely ill patients with extracorporeal respiratory or cardiovascular support.

Methods:

A series of 18 patients in the state of São Paulo, Brazil is described. All patients were consecutively evaluated by a multidisciplinary team at the hospital of origin. The patients were rescued, and extracorporeal membrane oxygenation support was provided on site. The patients were then transported to referral hospitals for extracorporeal membrane oxygenation support. Data were retrieved from a prospectively collected database.

Results:

From 2011 to 2017, 18 patients aged 29 (25 - 31) years with a SAPS 3 of 84 (68 - 92) and main primary diagnosis of leptospirosis and influenza A (H1N1) virus were transported to three referral hospitals in São Paulo. A median distance of 39 (15 - 82) km was traveled on each rescue mission during a period of 360 (308 - 431) min. A median of one (0 - 2) nurse, three (2 - 3) physicians, and one (0 - 1) physical therapist was present per rescue. Seventeen rescues were made by ambulance, and one rescue was made by helicopter. The observed complications were interruption in the energy supply to the pump in two cases (11%) and oxygen saturation < 70% in two cases. Thirteen patients (72%) survived and were discharged from the hospital. Among the nonsurvivors, there were two cases of brain death, two cases of multiple organ dysfunction syndrome, and one case of irreversible pulmonary fibrosis.

Conclusions:

Transportation with extracorporeal support occurred without serious complications, and the hospital survival rate was high.

Keywords:
Artificial, respiration; Respiratory insufficiency; Extracorporeal membrane oxygenation; Transportation of patients; Critical illness; Intensive care units

Characteristics	All patients (n = 18)	Survivors (n = 13)	Nonsurvivors (N = 5)	p value^* * Value of comparison between survivors and nonsurvivors;
Age (years)	29 [25 - 31]	28 [25 - 31]	29 [27 - 31]	0.621
Female	11 (61)	9 (69)	2 (40)	0.326
SAPS 3	84 [68 - 92]	84 [66 - 88]	80 [73 - 95]	0.961
Mortality predicted in South America (%)^† † calculation was performed using the logit of SAPS 3 for South America and Western Europe, respectively. The results are expressed as the median [interquartile 25 - 75] or the number (%).	89 [66 - 94]	89 [62 - 92]	86 [76 - 95]	1.000
Mortality predicted in Europe (%)^† † calculation was performed using the logit of SAPS 3 for South America and Western Europe, respectively. The results are expressed as the median [interquartile 25 - 75] or the number (%).	76 [46 - 85]	76 [42 - 81]	71 [58 - 88]	0.961
SOFA	13 [9 - 16]	14 [10 - 16]	13 [9 - 13]	0.584
Weight (kg)	74 [55 - 84]	72 [50 - 78]	84 [60 - 84]	0.298
Height (cm)	165 [160 - 185]	165 [160 - 170]	180 [160 - 185]	0.344
Associated clinical conditions				0.920
Systemic arterial hypertension	2 (11)	1 (8)	1 (20)
Diabetes mellitus	1 (9)	1 (8)	0 (0)
Gestational complications	1 (9)	1 (8)	0 (0)
Postpartum complications	3 (17)	3 (38)	0 (0)
Systemic lupus erythematosus	1 (9)	1 (8)	0 (0)
HIV/AIDS	1 (9)	0 (0)	1 (20)
Etiological diagnoses				0.810
Alveolar hemorrhage due to lupus	1 (9)	1 (8)	0 (0)
Leptospirosis	3 (17)	3 (38)	0 (0)
H3N2 Influenza A virus	1 (9)	0 (0)	1 (20)
H1N1 Influenza A virus	3 (17)	2 (38)	1 (20)
Influenza B virus	1 (9)	1 (8)	0 (0)
Varicella zoster virus	1 (9)	1 (8)	0 (0)
Respiratory syncytial virus	1 (9)	1 (8)	0 (0)
Coronavirus	1 (9)	1 (8)	0 (0)
Epstein-Barr virus	1 (9)	1 (8)	0 (0)
Nosocomial pneumonia	1 (9)	1 (8)	0 (0)
Aspiration pneumonia	1 (9)	0 (0)	1 (20)
Necrotizing pneumonia	1 (9)	0 (0)	1 (20)
Pelvic septic thrombophlebitis	1 (9)	1 (8)	0 (0)
Pneumocystis jirovecii	1 (9)	0 (0)	1 (20)

Characteristics	All patients (n = 18)	Survivors (n = 13)	Nonsurvivors (N = 5)	p value^* * Value of comparison between survivors and nonsurvivors. The results are expressed as the median [interquartile 25 - 75] or the number (%).
Murray score	3.7 [3.0 - 4.0]	3.5 [3.0 - 4.0]	3.8 [3.0-4.0]	0.448
Mechanical ventilation time (days)	7 [1 - 11]	5 [1 - 8]	8 [7-15]	0.113
ICU time (days)	7 [2 - 11]	5 [1 - 9]	8 [8-15]	0.199
RESP score	0.00 [-2.00 - 2.00]	1.50 [-0.25 - 3.25]	-2.00 [-3.00 - -1.00]	0.023
Survival rate (RESP) (%)	50 [40 - 60]	58 [48 - 69]	40 [35 - 45]	0.034
SAVE score	0.00	0.00	---	---
Survival rate (SAVE) (%)	40	40	---	---
Mechanical ventilation
Pressure-controlled mode	14 (78)	10 (77)	4 (80)	1.000
Volume-controlled mode	4 (22)	3 (23)	1 (20)
PEEP (cmH₂O)	14 [10 - 18]	12 [10 - 15]	17 [13 - 18]	0.269
FiO₂ (%)	100 [100 - 100]	100 [100 - 100]	100 [100 - 100]	0.288
Tidal volume (mL/kg)	4 [4 - 6]	5 [4 - 6]	3 [3 - 4]	< 0.001
Respiratory rate (ipm)	28 [25 - 35]	28 [25 - 35]	28 [28 - 35]	0.723
Plateau pressure (cmH₂O)	33 [30 - 35]	34 [30 - 35]	32 [31 - 35]	0.960
Blood gas analysis
pH	7.27 [7.08 - 7.35]	7.27 [7.09 - 7.35]	7.10 [7.00 - 7.34]	0.622
PaO₂ (mmHg)	54 [38 - 60]	58 [39 - 65]	50 [45 - 60]	0.882
PaCO₂ (mmHg)	61 [46 - 90]	53 [42 - 80]	90 [49 - 90]	0.429
SBE (mEq/L)	1.5 [-2.5 - 4.8]	1.0 [-3.0 - 6.0]	2.0 [0.0 - 4.0]	0.805
Lactate (mEq/L)	2.7 [2.2 - 3.9]	2.7 [2.2 - 3.3]	2.7 [2.7 - 4.4]	0.692
P/F ratio (mmHg)	55 [39 - 60]	60 [39 - 65]	50 [45 - 60]	0.657
Salvage therapy
Alveolar recruitment	15 (84)	10 (77)	5.100	0.638
Nitric oxide	2 (11)	0 (0)	2 (40)	0.114
Prone position	12 (67)	7 (54)	5.100	0.193
Curarization	15 (84)	10 (77)	5.100	0.638
TGI	2 (11)	0 (0)	2 (40)	1.000
Corticosteroids	12 (67)	8 (62)	4 (40)	0.852
Hemodynamic support
Noradrenaline	16 (89)	12 (92)	4 (80)	1.000
Vasopressin	4 (22)	1 (8)	3 (60)	0.078
Adrenaline	3 (17)	1 (8)	2 (40)	1.000
Dobutamine	3 (17)	3 (23)	0 (0)	0.638

Characteristics	All patients (n = 18)	Survivors (n = 13)	Nonsurvivors (N = 5)	p value^* * Value of comparison between survivors and nonsurvivors. The results are expressed as the number (%) or the median [interquartile 25 - 75].
Hospital of origin
Public	13 (72)	9 (69)	4 (80)	0.057
Private	5 (28)	4 (31)	1 (20)
Referral hospital
Public	14 (78)	10 (77)	4 (80)	1.000
Private	4 (22)	3 (23)	1 (20)
Mission time (minutes)	360 [308 - 431]	360 [300 - 420]	420 [345 - 435]	0.520
Distance traveled (km)	39 [15 - 82]	40 [12 - 90]	37 [23 - 40]	1.000
Professionals involved
Nurses (number per mission)	1 [0 - 2]	1 [0 - 2]	1 [1 - 2]	0.675
Doctors (number per mission)	3 [2 - 3]	3 [2 - 3]	2 [2 - 3]	0.437
Physical therapists (number per mission)	1 [0 - 1]	1 [0 - 1]	1 [0 - 1]	1.000
Transportation vehicle
Ambulance	17 (94)	12 (92)	5.100	1.000
Helicopter	1 (6)	1 (8)	0 (0)
Complications
Insufficient power	2 (11)	1 (8)	1 (20)	1.000
SpO₂ < 70%	2 (11)	2 (16)	0 (0)	0.890
SpO₂ < 85%	4 (22)	2 (16)	2 (40)	0.900
Hemodynamic worsening	0 (0)	0 (0)	0 (0)	1.000
Temperature < 35 °C	1 (6)	1 (8)	0 (0)	0.900

Characteristics	All patients (n = 18)	Survivors (n = 13)	Nonsurvivors (N = 5)	p value^* * Value of comparison between survivors and nonsurvivors;
Cannulation
Veno-venous ECMO	17 (94)	12 (92)	5.100	1.000
Veno-arterial ECMO	1 (6)	1 (8)	0 (0)
Initial settings for ECMO
Blood flow (mL/min)	4725 [4.300 - 5.498]	4500 [4.300 - 5.400]	5000 [4.300 - 6.400]	0.521
Sweep flow (L/min)	6.0 [4.0 - 8.0]	4,5 [4.0 - 8.0]	6.0 [6.0 - 10.0]	0.136
FiO₂ (%)	100 [100 - 100]	100 [100 - 100]	100 [100 - 100]	1.000
Initial fan settings
PSV mode	3 (17)	3 (23)	0 (0)	0.372
PCV mode	14 (78)	9 (69)	5.100
APRV mode	1 (6)	1 (8)	0 (0)
Tidal volume (mL/kg)	2.1 [0.89 - 2.71]	2.33 [0.80 - 2.93]	0.95 [0.91 - 2.20]	0.460
PEEP (cmH2O)	10 [10 - 10]	10 [10 - 10]	10 [10 - 12]	0.105
Plateau pressure (cmH₂O)	20 [20 - 20]	20 [20 - 20]	20 [20 - 25]	0.088
FiO₂ (%)	30 [30 - 38]	30 [30 - 30]	30 [30 - 60]	0.736
Respiratory rate (inspirations/min.)	10 [10 - 10]	10 [10 - 10]	10 [10 - 10]	0.543
Post-ECMO blood gas analysis
pH	7.39 [7.37 - 7.44]	7.39 [7.36 - 7.40]	7.46 [7.40 - 7.51]	0.080
PaO₂ (mmHg)	61 [52 - 68]	62 [52 - 68]	53 [49 - 65]	0.375
PaCO₂ (mmHg)	38 [36 - 42]	40 [36 - 44]	36 [33 - 36]	0.048
SBE (mEq/L)	1.3 [-0.6 - 4.2]	1.0 [-0.5 - 4.0]	1.6 [-3.4 - 8.4]	0.921
PaO₂ < 40mmHg in ECMO^# # persistent for more than 6 hours. The results are expressed as the number (%) or the median [interquartile 25 - 75].	5 (28)	3 (23)	2 (40)	0.896
Positive blood cultures at admission
Candida sp.	3 (17)	2 (15)	1 (20)	1.000
Pseudomonas aeruginosa	2 (11)	1 (8)	1 (20)	0.490
Klebsiella pneumoniae	1 (6)	0 (0)	1 (20)	0.278
Proteus mirabilis	1 (6)	1 (8)	0 (0)	1.000
Renal replacement therapy
Continuous	10 (56)	7 (54)	3 (60)	1.000
Intermittent	6 (33)	6 (46)	0 (0)	0.192
Not used	8 (44)	6 (46)	2 (40)	1.000
Nosocomial infections acquired upon arrival at the referral hospital
PAV	1 (6)	1 (8)	0 (0)	0.900
UTI	1 (6)	0 (0)	1 (20)	0.278
Catheter infection	0 (0)	0 (0)	0 (0)	1.000

Characteristics	All patients (n = 18)	Survivors (n = 13)	Nonsurvivors (N = 5)	p value^* * Value of comparison between survivors and nonsurvivors;
Hospital discharge	13 (72)	13 (100)	0 (0)	---
ICU discharge	13 (72)	13 (100)	0 (0)	---
ECMO weaning	15 (84)	13 (100)	2 (40)	---
MV weaning	13 (72)	13 (100)	0 (0)	---
Tracheostomized	5 (28)	5 (38)	0 (0)	---
ECMO time (days)	6 [4-9]	5 [4-9]	6 [3-10]	1.000
MV time (days)	7 [6-18]	7 [6-12]	6 [5-20]	0.580
ICU time (days)	15 [10-21]	16 [12-21]	6 [3-20]	0.289
Length of hospitalization (days)	25 [14-50]	28 [24-50]	6 [3-20]	0.084
Oxygen dependence after discharge	0 (0)	0 (0)	0 (0)	---
Need for dialysis after discharge	1 (6)	1 (8)	0 (0)	---
Cause of death
Brain death^† † patients with support withdrawal; ^‡ ‡ one patient with extensive brain hemorrhage and one patient with diffuse ischemia and secondary bleeding;	---	---	2 (40)	---
Multiple organ dysfunction syndrome	---	---	2 (40)	---
Irreversible pulmonary fibrosis^¶ ¶ irreversible fibrosis characterized by the complete absence of vascular scaffold in open lung biopsy after 60 days of support with extracorporeal membrane oxygenation and without signs of improvement. The results are expressed as number (%) or median [interquartile 25-75].	---	---	1 (20)	---

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[1] Corresponding author: Marcelo Park, Disciplina de Emergências, Unidade de Terapia Intensiva, Hospital das Clínicas, Avenida Dr. Enéas Carvalho de Aguiar, 255, 6º andar, sala 6.040, Zip code: 05403-000 - São Paulo (SP), Brazil, E-mail: marcelo.park@hc.fm.usp.br