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Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations.
Clin Toxicol (Phila). 2021 Oct; 59(10):877-887.CT

Abstract

CONTEXT

Poisoning may lead to respiratory failure, shock, cardiac arrest, or death. Extracorporeal membrane oxygenation (ECMO) may be used to provide circulatory support, termed venoarterial (VA) ECMO; or respiratory support termed venovenous (VV) ECMO. The clinical utility of ECMO in poisoned patients remains unclear and guidelines on its use in this setting are lacking.

OBJECTIVES

To perform a literature search and narrative review on the use of ECMO in poisonings. Additionally, to provide recommendations on the use of ECMO in poisonings from physicians with expertise in ECMO, medical toxicology, critical care, and emergency medicine.

METHODS

A literature search in Ovid MEDLINE from 1946 to October 14, 2020, was performed to identify relevant articles with a strategy utilizing both MeSH terms and adjacency searching that encompassed both extracorporeal life support/ECMO/Membrane Oxygenation concepts and chemically-induced disorders/toxicity/poisoning concepts, which identified 318 unique records. Twelve additional manuscripts were identified by the authors for a total of 330 articles for screening, of which 156 were included for this report.

NARRATIVE LITERATURE REVIEW

The use of ECMO in poisoned patients is significantly increasing over time. Available retrospective data suggest that patients receiving VA ECMO for refractory shock or cardiac arrest due to poisoning have lower mortality as compared to those who receive VA ECMO for non-poisoning-related indications. Poisoned patients treated with ECMO have reduced mortality as compared to those treated without ECMO with similar severity of illness and after adjusted analyses, regardless of the type of ingestion. This is especially evident for poisoned patients with refractory cardiac arrest placed on VA ECMO (termed extracorporeal cardiopulmonary resuscitation [ECPR]).

INDICATIONS

We suggest VA ECMO be considered for poisoned patients with refractory cardiogenic shock (continued shock with myocardial dysfunction despite fluid resuscitation, vasoactive support, and indicated toxicologic therapies such as glucagon, intravenous lipid emulsion, hyperinsulinemia euglycemia therapy, or others), and strongly considered for patients with cardiac arrest in institutions which are structured to deliver effective ECPR. VV ECMO should be considered in poisoned patients with ARDS or severe respiratory failure according to traditional indications for ECMO in this setting.

CONTRAINDICATIONS

Patients with pre-existing comorbidities with low expected survival or recovery. Relative contraindications vary based on each center's experience but often include: severe brain injury; advanced age; unrepaired aortic dissection or severe aortic regurgitation in VA ECMO; irreversible organ injury; contraindication to systemic anticoagulation, such as severe hemorrhage.

CONCLUSIONS

ECMO may provide hemodynamic or respiratory support to poisoned patients while they recover from the toxic exposure and metabolize or eliminate the toxic agent. Available literature suggests a potential benefit for ECMO use in selected poisoned patients with refractory shock, cardiac arrest, or respiratory failure. Future studies may help to further our understanding of the use and complications of ECMO in poisoned patients.

Authors+Show Affiliations

Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA. Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.Cardiothoracic ICU, National University Hospital, Singapore, Singapore. Paediatric ICU, The Royal Children's Hospital, Melbourne, Australia.Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA.Department of Emergency Medicine, Section of Medical Toxicology, Oregon Health and Science University, Portland, OR, USA.

Pub Type(s)

Journal Article
Systematic Review

Language

eng

PubMed ID

34396873

Citation

Upchurch, Cameron, et al. "Extracorporeal Membrane Oxygenation Use in Poisoning: a Narrative Review With Clinical Recommendations." Clinical Toxicology (Philadelphia, Pa.), vol. 59, no. 10, 2021, pp. 877-887.
Upchurch C, Blumenberg A, Brodie D, et al. Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations. Clin Toxicol (Phila). 2021;59(10):877-887.
Upchurch, C., Blumenberg, A., Brodie, D., MacLaren, G., Zakhary, B., & Hendrickson, R. G. (2021). Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations. Clinical Toxicology (Philadelphia, Pa.), 59(10), 877-887. https://doi.org/10.1080/15563650.2021.1945082
Upchurch C, et al. Extracorporeal Membrane Oxygenation Use in Poisoning: a Narrative Review With Clinical Recommendations. Clin Toxicol (Phila). 2021;59(10):877-887. PubMed PMID: 34396873.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations. AU - Upchurch,Cameron, AU - Blumenberg,Adam, AU - Brodie,Daniel, AU - MacLaren,Graeme, AU - Zakhary,Bishoy, AU - Hendrickson,Robert G, Y1 - 2021/08/16/ PY - 2021/8/17/pubmed PY - 2021/11/9/medline PY - 2021/8/16/entrez KW - ECLS KW - ECMO KW - ECPR KW - cardiac arrest KW - overdose KW - poisoning KW - respiratory failure KW - shock KW - toxin SP - 877 EP - 887 JF - Clinical toxicology (Philadelphia, Pa.) JO - Clin Toxicol (Phila) VL - 59 IS - 10 N2 - CONTEXT: Poisoning may lead to respiratory failure, shock, cardiac arrest, or death. Extracorporeal membrane oxygenation (ECMO) may be used to provide circulatory support, termed venoarterial (VA) ECMO; or respiratory support termed venovenous (VV) ECMO. The clinical utility of ECMO in poisoned patients remains unclear and guidelines on its use in this setting are lacking. OBJECTIVES: To perform a literature search and narrative review on the use of ECMO in poisonings. Additionally, to provide recommendations on the use of ECMO in poisonings from physicians with expertise in ECMO, medical toxicology, critical care, and emergency medicine. METHODS: A literature search in Ovid MEDLINE from 1946 to October 14, 2020, was performed to identify relevant articles with a strategy utilizing both MeSH terms and adjacency searching that encompassed both extracorporeal life support/ECMO/Membrane Oxygenation concepts and chemically-induced disorders/toxicity/poisoning concepts, which identified 318 unique records. Twelve additional manuscripts were identified by the authors for a total of 330 articles for screening, of which 156 were included for this report. NARRATIVE LITERATURE REVIEW: The use of ECMO in poisoned patients is significantly increasing over time. Available retrospective data suggest that patients receiving VA ECMO for refractory shock or cardiac arrest due to poisoning have lower mortality as compared to those who receive VA ECMO for non-poisoning-related indications. Poisoned patients treated with ECMO have reduced mortality as compared to those treated without ECMO with similar severity of illness and after adjusted analyses, regardless of the type of ingestion. This is especially evident for poisoned patients with refractory cardiac arrest placed on VA ECMO (termed extracorporeal cardiopulmonary resuscitation [ECPR]). INDICATIONS: We suggest VA ECMO be considered for poisoned patients with refractory cardiogenic shock (continued shock with myocardial dysfunction despite fluid resuscitation, vasoactive support, and indicated toxicologic therapies such as glucagon, intravenous lipid emulsion, hyperinsulinemia euglycemia therapy, or others), and strongly considered for patients with cardiac arrest in institutions which are structured to deliver effective ECPR. VV ECMO should be considered in poisoned patients with ARDS or severe respiratory failure according to traditional indications for ECMO in this setting. CONTRAINDICATIONS: Patients with pre-existing comorbidities with low expected survival or recovery. Relative contraindications vary based on each center's experience but often include: severe brain injury; advanced age; unrepaired aortic dissection or severe aortic regurgitation in VA ECMO; irreversible organ injury; contraindication to systemic anticoagulation, such as severe hemorrhage. CONCLUSIONS: ECMO may provide hemodynamic or respiratory support to poisoned patients while they recover from the toxic exposure and metabolize or eliminate the toxic agent. Available literature suggests a potential benefit for ECMO use in selected poisoned patients with refractory shock, cardiac arrest, or respiratory failure. Future studies may help to further our understanding of the use and complications of ECMO in poisoned patients. SN - 1556-9519 UR - https://www.unboundmedicine.com/medline/citation/34396873/Extracorporeal_membrane_oxygenation_use_in_poisoning:_a_narrative_review_with_clinical_recommendations_ L2 - https://www.tandfonline.com/doi/full/10.1080/15563650.2021.1945082 DB - PRIME DP - Unbound Medicine ER -