Extracorporeal membrane oxygenation in adult patients with hematologic malignancies and severe acute respiratory failure

Wohlfarth et al. Critical Care Extracorporeal membrane oxygenation in adult patients with hematologic malignancies and severe acute respiratory failure Philipp Wohlfarth 0 Roman Ullrich 2 Thomas Staudinger 0 Andja Bojic 0 Oliver Robak 0 Alexander Hermann 0 Barbara Lubsczyk 2 Nina Worel 1 Valentin Fuhrmann 4 Maria Schoder 3 Martin Funovics 3 Werner Rabitsch 0 Paul Knoebl 0 Klaus Laczika 0 Gottfried J Locker 0 Wolfgang R Sperr 0 Peter Schellongowski 0 Arbeitsgruppe fr hmato-onkologische Intensivmedizin der sterreichischen Gesellschaft fr Internistische und Allgemeine Intensivmedizin und Notfallmedizin (GIAIN) 0 Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Medical University of Vienna , Waehringer Guertel 18-20, A-1090 Vienna , Austria 1 Department of Bloodgroup Serology and Transfusion Medicine, Medical University of Vienna , Waehringer Guertel 18-20, A-1090 Vienna , Austria 2 Department of Anaesthesia, Intensive Care Unit 13c2, Medical University of Vienna , Waehringer Guertel 18-20, A-1090 Vienna , Austria 3 Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna , Waehringer Guertel 18-20, A-1090 Vienna , Austria 4 Department of Medicine III, Intensive Care Unit 13h1, Medical University of Vienna , Waehringer Guertel 18-20, A-1090 Vienna , Austria Introduction: Acute respiratory failure (ARF) is the main reason for intensive care unit (ICU) admissions in patients with hematologic malignancies (HMs). We report the first series of adult patients with ARF and HMs treated with extracorporeal membrane oxygenation (ECMO). Methods: This is a retrospective cohort study of 14 patients with HMs (aggressive non-Hodgkin lymphoma (NHL) n = 5; highly aggressive NHL, that is acute lymphoblastic leukemia or Burkitt lymphoma, n = 5; Hodgkin lymphoma, n = 2; acute myeloid leukemia, n = 1; multiple myeloma, n = 1) receiving ECMO support because of ARF (all data as medians and interquartile ranges; age, 32 years (22 to 51 years); simplified acute physiology score II (SAPS II): 51 (42 to 65)). Etiology of ARF was pneumonia (n = 10), thoracic manifestation of NHL (n = 2), sepsis of nonpulmonary origin (n = 1), and transfusion-related acute lung injury (n = 1). Diagnosis of HM was established during ECMO in four patients, and five first received (immuno-) chemotherapy on ECMO. Results: Before ECMO, the PaO2/FiO2 ratio was 60 (53 to 65), (3.3 to 3.7). Three patients received venoarterial ECMO because of acute circulatory failure in addition to ARF; all other patients received venovenous ECMO. All patients needed vasopressors, and five needed hemofiltration. Thrombocytopenia occurred in all patients (lowest platelet count was 20 (11 to 21) G/L). Five major bleeding events were noted. ECMO duration was 8.5 (4 to 16) days. ICU and hospital survival was 50%. All survivors were alive at follow-up (36 (10 to 58) months); five patients were in complete remission, one in partial remission, and one had relapsed. Conclusions: ECMO therapy is feasible in selected patients with HMs and ARF and can be associated with long-term disease-free survival. - Introduction The acute respiratory failure (ARF) represents the predominant reason for medical intensive care unit (ICU) admissions in patients with hematologic malignancies (HMs) [1-5]. Its occurrence has a strong prognostic impact, especially if mechanical ventilation becomes necessary. Although the outcome of those affected was described to be dismal in the past, survival improved markedly in recent years. This development may be attributed to advances in patient selection [6], general improvements in the management of the acute respiratory distress syndrome (ARDS), as well as specific improvements in managing ARF in patients with HMs. The latter comprises specific diagnostic algorithms in ARF of HM patients [7], as well as the use of noninvasive ventilation early in the course, even though the efficacy of this procedure does not remain undisputed [8-11]. However, mortality rates of patients with HMs and invasive mechanical ventilation due to ARF still exceed 50% [1,3-5]. Yet, a general reluctance to admit critically ill patients with HMs cannot be justified. Unlimited intensive care has been advocated for selected patients with HMs [12,13]. The extracorporeal membrane oxygenation (ECMO) depicts one of the ultimate therapies in intensive care and may possibly be beneficial in patients with ARDS in general ICU populations [14,15]. Some data exist on the use of ECMO in cohorts of children with malignant diseases [16,17], but the published experience with ECMO in adult patients with HM is limited to two single cases [18,19]. Because both, patients with HMs and those undergoing ECMO are prone to acquire severe complications, such as bleeding and infection [1,5,20-23], performing ECMO in patients with HMs might bear a particularly high risk. The purpose of this analysis is to report the characteristics and outcomes of patients with HMs and ARF treated with ECMO. Materials and methods We retrospectively studied the clinical courses of all adult patients (18 years or older) with HMs and ARF treated with ECMO at the Medical University of Vienna, General Hospital, between September 2000 and June 2013. This study was conducted in accordance with the amended Declaration of Helsinki. The ethics committee of the Medical University of Vienna approved the protocol and waived the need for informed consent because of the noninterventional retrospective design of the investigation. The presence of ARDS was defined and graded according to recently introduced criteria [24]. The term baseline refers to the time immediately before the start of ECMO treatment. Thrombocytopenia was defined as platelet count <150 G/L, and leukocytopenia as leukocyte count <4 G/L. In our center, extracorporeal lung support is usually evaluated in patients presenting with severe and life-threatening hypoxemia while being mechanically ventilated with adequately high positive end-expiratory pressure (PEEP) and a missing response to supportive measures like prone positioning. During ECMO, a maximally achievable protective ventilation setting is desired. Weaning from ECMO is performed according to current Extracorporeal Life Support Organization (ELSO) guidelines [25]. At baseline, we recorded age, gender, characteristics of the hematologic malignancy, including type and stage of the respective malignancy, time of diagnosis, type and timing of previous specific treatments (that is, chemo-, immuno-, or radiotherapy, autologous or allogeneic stem cell transplantation (ASCT)), as well as the intention of cancer treatment (curative versus noncurative). The Charlson Comorbidity Index [26] (CCI) was assessed to account for comorbid conditions. To grade the severity of illness, we calculated the Simplified Acute Physiology Score II (SAPS II) [27,28] at ICU admission, as wel (...truncated)