Elsevier

The Lancet

Volume 396, Issue 10250, 22–28 August 2020, Pages 545-552
The Lancet

Articles
Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study

https://doi.org/10.1016/S0140-6736(20)30733-9Get rights and content

Summary

Background

Patients with sepsis-induced cardiomyopathy with cardiogenic shock have a high mortality. This study assessed venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for sepsis-induced cardiogenic shock refractory to conventional treatments.

Methods

In this retrospective, multicentre, international cohort study, we compared outcomes of 82 patients (aged ≥18 years) with septic shock who received VA-ECMO at five academic ECMO centres, with 130 controls (not receiving ECMO) obtained from three large databases of septic shock. All patients had severe myocardial dysfunction (cardiac index 3 L/min per m2 or less or left ventricular ejection fraction [LVEF] 35% or less) and severe haemodynamic compromise (inotrope score at least 75 μg/kg per min or lactic acidaemia at least 4 mmol/L) at time of inclusion. The primary endpoint was survival at 90 days. A propensity score-weighted analysis was done to control for confounders.

Findings

At baseline, patients treated with VA-ECMO had more severe myocardial dysfunction (mean cardiac index 1·5 L/min per m2 vs 2·2 L/min per m2, LVEF 17% vs 27%), more severe haemodynamic impairment (inotrope score 279 μg/kg per min vs 145 μg/kg per min, lactataemia 8·9 mmol/L vs 6·5 mmol/L), and more severe organ failure (Sequential Organ Failure Assessment score 17 vs 13) than did controls, with p<0·0001 for each comparison. Survival at 90 days for patients treated with VA-ECMO was significantly higher than for controls (60% vs 25%, risk ratio [RR] for mortality 0·54, 95% CI [0·40–0·70]; p<0·0001). After propensity score weighting, ECMO remained associated with improved survival (51% vs 14%, adjusted RR for mortality 0·57, 95% CI [0·35–0·93]; p=0·0029). Lactate and catecholamine clearance were also significantly enhanced in patients treated with ECMO. Among the 49 survivors treated with ECMO, 32 who had been treated at the largest centre reported satisfactory Short Form-36 evaluated health-related quality of life at 1-year follow-up.

Interpretation

Patients with severe sepsis-induced cardiogenic shock treated with VA-ECMO had a large and significant improvement in survival compared with controls not receiving ECMO. However, despite the careful propensity-weighted analysis, we cannot rule out unmeasured confounders.

Funding

None.

Introduction

Sepsis remains a major issue worldwide. In the USA alone, sepsis is responsible for 1·7 million admissions to hospital annually, and has a mortality of 35%–50% when septic shock is present.1, 2 Transient reversible myocardial dysfunction is a common feature during septic shock, affecting 20–65% of patients.3, 4 Although mild decreases in left ventricular ejection fraction (LVEF) combined with left ventricular dilation and a preserved cardiac index appear to be associated with a good survival,3, 4 the mortality of patients with severe myocardial dysfunction and decreased cardiac index might exceed 80%.3, 5, 6 The incidence of this condition in adults is uncertain, but could be up to 24% of patients with septic shock requiring more than 24 h of vasopressors,5 translating to more than 25 000 episodes annually in the USA.1

Use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during septic shock refractory to conventional treatment remains controversial. Encouraging results in children with survival rates ranging from 50% to 75%,7, 8 led to the inclusion of this therapeutic option in recent paediatric guidelines of septic shock,8 whereas data in adults have been more equivocal.9, 10, 11, 12, 13, 14 In this study, we aimed to assess the use of VA-ECMO in adults with sepsis-induced cardiogenic shock refractory to conventional treatments.

Section snippets

Study design

In this retrospective, international, multicentre study we compared outcomes of patients who received VA-ECMO for refractory sepsis-induced cardiogenic shock with patients who did not. Data for patients with ECMO were obtained from databases of five university hospital ECMO centres (La Pitié-Salpêtrière, Paris, Amiens, Nancy, and Rennes University Hospitals, France; and Columbia University Medical Centre/New York-Presbyterian Hospital, New York, NY, USA). Data for patients with severe septic

Results

82 patients who received VA-ECMO for sepsis-induced cardiogenic shock were included in the analysis. Baseline characteristics are given in table 1. Community-acquired pneumonia accounted for the largest proportion of infections. 44 (54%) of 82 patients had sustained bacteraemia. Staphylococcus aureus and Streptococcus pneumonia, gram-negative bacteria, and non-pneumococcal streptococci were responsible for 26 (32%), 20 (24%), 24 (29%), and 12 (15%) of 82 episodes, respectively.

ECMO was used

Discussion

Our major finding is that the 90-day survival of patients treated with VA-ECMO was substantially improved compared with propensity-weighted patients with similar characteristics who were treated with medical management alone. VA-ECMO permitted a rapid decrease in vasopressor dose, and restored adequate perfusion of vital organs, as indicated by relatively rapid decreases in serum lactate. Improvement of cardiac function was also relatively quick and permitted weaning of ECMO support after a

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