RESUMEN
Non-invasive ventilation (NIV) might be successful if carefully selected in adult patients with cardiac dysfunction presenting with community-acquired pneumonia. The main objective of this study was to identify the early predictors of NIV failure. Adult patients with left ventricle ejection fraction (LV EF) <50% admitted to the intensive care unit (ICU) with community-acquired pneumonia and acute respiratory failure were enrolled in this multicenter prospective study after obtaining informed consents (study registrationID: ISRCTN14641518). Non-invasive ventilation failure was defined as the requirement of intubation after initiation of NIV. All patients were assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores at admission, while their Heart rate Acidosis Consciousness Oxygenation and Respiratory rate (HACOR) and lung ultrasound (LUS) scores in addition to blood lactate were assessed at NIV initiation and 12 and 24 hours later. A total of 177 patients were prospectively enrolled from February 2019 to July 2020. Of them, 53 (29.9%) had failed NIV. The mean age of the study cohort was 64.1+or- 12.6 years, with a male predominance (73.4%) and a mean LV EF of 36.4 +or- 7.8%. Almost 55.9% of the studied patients had diabetes mellitus, 45.8% had chronic systemic hypertension, 73.4% had ischemic heart disease, 20.3% had chronic kidney disease, and 9.6% had liver cirrhosis. No significant differences were observed between the NIV success and NIV failure groups regarding underlying morbidities or inflammatory markers. Patients who failed NIV were significantly older and had higher mean SOFA and APACHE II scores than those with successful NIV. We also found that NIV failure was associated with longer ICU stay (p < 0.001), higher SOFA scores at 48 hours (p < 0.001) and higher mortality (p < 0.001) compared with the NIV success group. In addition, SOFA (Odds Ratio (OR): 4.52, 95% Confidence Interval (CI): 2.59-7.88, p < 0.001), HACOR (OR: 2.01, 95% CI: 0.97-4.18, p = 0.036) and LUS (OR: 1.33, 95% CI: 1.014-1.106, p = 0.027) scores and blood lactate levels (OR: 9.35, 95% CI: 5.32-43.26, p < 0.001) were independent factors for NIV failure. High initial HACOR and SOFA scores, persistent hyperlactatemia and non-decrementing LUS score were associated with early NIV failure in patients with cardiac dysfunction presenting with community-acquired pneumonia, and could be used as clinical and paraclinical variables for early decision making regarding invasive ventilation.
RESUMEN
Background: Emergent peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used frequently to support patients with refractory cardiogenic shock with variable rates of complications. We retrospectively analyzed adult patients who received peripheral VA-ECMO support between 2015 and 2019 at our tertiary care hospital. Results: Sixty five patients with a mean age of 37.9 +/- 14.9 years, mostly males (70.8%), were supported with femoral VA-ECMO with a median duration of 8 (IQR: 3-40) days. Hospital mortality occurred in 29 (44.6%) patients. Complications included acute kidney injury (AKI) in 39 (60%), acute cerebral strokes in 13 (20%), gastrointestinal bleeding in 14 (21.5%) and acute limb ischemia in 21 (32.3%) patients. Non-survivors had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores and significantly increased rates of acute kidney injury, renal replacement therapy, ischemic cerebral strokes, cannulation site exploration for bleeding, atrial fibrillation and anticoagulation discontinuation. Multivariable regression analysis revealed significant Odds Ratios (OR), 95% Confidence Intervals (CI) of hospital mortality with: increasing SOFA scores after 48 hours (2.15, 1.441-3.214, p < 0.001), atrial fibrillation (11.351, 1.354-83.222, p = 0.025) and hyperlactatemia (2.74, 1.448-6.719, p = 0.016). Conclusion: High mortality and frequent morbidities due to emergent peripheral VA-ECMO should be considered before initiation for cardiogenic shock. According to our results, increasing trend of SOFA scores, atrial fibrillation and progressive hyperlactatemia are independent predictors of hospital mortality of peripheral VAECMO.