Patients with hematologic malignancies have many reasons to die during extracorporeal membrane oxygenation
Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hopital de la Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris
Authors' response Philipp Wohlfarth, Thomas Staudinger and Peter Schellongowski
We read with great interest the article by Wohlfarth and colleagues  regarding the use of extracorporeal membrane oxygenation (ECMO) in 14 adult patients with hematological malignancies. We would like to highlight two main points. First, the authors focused their report and their discussion on bleeding complications and anticoagulation management in this high-risk population. Although we concede that it is a serious concern in these patients, it is not the only one. ECMO support is associated with nosocomial infections [2,3]. Impairment of cellular immunity, cytopenia and chemotherapy (CT) may further increase the risks of infection and may dissuade clinicians from using ECMO in these patients. Developing new strategies that aim to limit nosocomial infections is crucial to improving outcomes in this population. ECMO in awake, non-intubated, spontanWe thank the authors for their thoughtful considerations. Eight of the ten cases of pneumonia leading to ECMO were hospital-acquired. However, the number of proven infections during the ICU stay was low. Of 110 cultures (broncho-alveolar lavage, blood, urine, catheters, stool, pleural/pericardial effusion, lung biopsies, wound swaps, cerebrospinal fluid), only 6 were positive (catheter-related infection, n = 5; urinary tract infection, n = 1). Reactivation of cytomegalovirus or herpes simplex virus occurred in one and three patients, respectively. All patients had received broad-spectrum antibiotics, eight of them plus antifungals.
eously breathing patients with acute respiratory distress
syndrome, to avoid mechanical ventilation and its related
adverse events, is a potentially promising application .
Thus, in our opinion, it would also be important to provide
a thorough description of nosocomial infections that might
have occurred in these 14 patients.
Second, the authors reported that 5 of 14 patients initially
received CT while receiving ECMO. The pharmacokinetics
of many of the medications administered to patients
receiving ECMO are complex  and, to date, there are
very limited data to guide our daily practice. Therefore,
clinicians must be aware that providing CT to patients
receiving ECMO is a potential gamble, which risks
worsening patient outcomes due to ineffective drug
regimens. CT during ECMO should be restricted to those
cases where postponing therapy is not an option.
Even apart from ECMO, optimal timing,
pharmacokinetics and, therefore, dosing of CT in patients with acute
organ dysfunctions is largely unknown. Nevertheless, CT
may be the only option if hematologic malignancies
themselves cause organ dysfunction, especially in
pulmonary involvement . Nowadays, administration of CT is
common practice in critically ill patients and affects every
fourth ICU patient with hematologic malignancies in
dedicated centers . Importantly, CT does not negatively
influence survival in large cohorts, even in cases of subsequent
sepsis [7-9]. By clinical judgment, postponing CT was not
an option in any of our five patients, of whom three are in
complete remission after 13, 15 and 46 months.
As a survival benefit of veno-venous ECMO still has
to be proven in patients with acute respiratory failure,
thorough case-by-case evaluation is absolutely essential.
2014 Schmidt et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
According to our findings, the risk of nosocomial infections
or CT-related issues should not lead to general exclusion
of patients with hematologic malignancies from ECMO.
Further research is warranted.
MS declares that they have no competing interests. DB reports receiving
research support from Maquet Cardiovascular, including travel expenses for
research meetings, as well as anticipated support for upcoming studies and
compensation paid to Columbia University for research consulting. He
receives no direct compensation from Maquet. He is a member of the
Medical Advisory Board for ALung Technologies. Compensation is paid to
Columbia University; he receives no direct compensation from ALung
Technologies. AC is the primary investigator of the EOLIA trial, NCT01470703,
a randomized trial of VV-ECMO supported in part by MAQUET. AC has
received honoraria for lectures by MAQUET.
Source of funding: MS was supported by The French Intensive Care Society
(SRLF), the 'Fonds de dotation Recherche en Sant Respiratoire, 2012', the
'Collge des Enseignants de Ranimation Mdicale' and the 'Fonds dEtudes
et de Recherche du Corps Mdical, Assistance publique-Hpitaux de Paris'.