ECMO in oncology and immunosupressed patients. Peter Schellongowski Department of Medicine I Intensive Care Unit 13.i2 Medical University of Vienna

Transcription

1 ECMO in oncology and immunosupressed patients Peter Schellongowski Department of Medicine I Intensive Care Unit 13.i2 Medical University of Vienna

2 ECMO in immunocompromised patients? Is it feasible? Is it safe? Is it effective? What are (contra) indications? Are there any specifics? Should we use it?

3 2,355 ELSO registry patients treated for acute respiratory failure 2000 to 2012 Multivariable risk prediction score 121 patients (5%) immunocompromised (IS) -> hematologic malignancy, solid tumor, solid organ transplant, HIV, cirrhosis Survival IS vs. non-is: 40% vs. 60%, p< Schmidt et al, AJRCCM 2014

4 Schmidt et al, AJRCCM 2014

5 Schmidt et al, AJRCCM 2014

6 What is immunosuppression? Hemalogic malignancy Solid tumor Bone marrow transplant HIV Solid organ transplant Systemic (rheumatologic) disease Immunosuppressive therapy diabetes?... cirrhosis?... post-sepsis syndrome?... Schmidt et al, AJRCCM 2014

7 Schuster, n=52 Estopa, n=30 Peter, n=118 Groeger, n=782 Azoulay, n=237 Benoit, n=124 Depuydt, n=166 Soares, n=463 Lecuyer, n=967 Gristina, n=597 Azoulay, n=1.004 Mortality of cancer patients undergoing IMV 100 % 90 90% 80 80% 70 70% 60 60% 50 50% 40 40% % % % 0 0 % - 40% ARDS: 52% Schellongowski, Med Klin Intensivmed Notfmed 2013 (adopted)

8 Mortality of cancer patients according to ARDS severity Azoulay et al, ICM 2014

9 ELSO registry data: Cancer patients Observational period: Cancer patients: n = 72 - solid tumor 47 (65%) - hematologic 21 (30%) - SCT 4 (6%) ECMO: - Pulmonary 54 (75%) - Cardiac 10 (14%) - CPR 8 ( 11%) Gow et al, Am J Surg 2010

10 ELSO registry data: Cancer patients Cancer patients: 32% hospital survival Gow et al, Am J Surg 2010

11 ELSO registry data: Cancer patients Complications Cancer vs. non-cancer GI hemorrhage: 9.7 vs. 4.4%; p=0.04 Dialysis: 36.1 vs. 18.7%; p<0.001 Infectious complications: 38.9 vs. 22%; p<0.001 Gow et al, Am J Surg 2010

12 Case reports Pubmed: Cancer: Condition: ECMO plus cancer or leukemia or lymphoma -> 18 single case reports ( ) 13 hematologic (3 SCT), 5 solid tumors 15 circulatory - 11 thoracic masses - 2 embolism, 1 myocarditis, 1 5-FU 3 pulmonary - 2 sepsis/ards - 1 IPS ECMO: 13 va ECMO, 5 vv ECMO Survival: 13/18 = 72%

13 Case series hema ECMO patients - Vienna (n=14) Diagnosis on ECMO n=4 PaO 2 /FiO 2 60 (53-65) Platelets: 20 (11-21) G/L Follow-Up (36 months): all 7 survivors alive 6 remission 1 relapse Chemotherapy on ECMO n=5 7/14 ( 50%) Wohlfarth et al, Crit Care 2014

14 Case series hema ECMO patients - Korea (n=15) Kang et al, Korean J Intern Med 2015

15 Case series hema ECMO patients - Korea (n=15) Survival in immunocompetent controll group: 8/33 = 24% Kang et al, Korean J Intern Med 2015

16 What have we got? Registry data (historic): n = 72 Single cases: n = 18 Case series (2): n = 29 Survival: 45/119 = 38% only respiratory 23/96 = 24%

17 VV-ECMO in allo SCT recipients submitted

18 Mortality of allo SCT patients undergoing IMV 90-Day Survival: 29% Lengline, Bone Marrow Transplant 2015

19 Awake ECMO for prevention of intubation? Hoeper et al, ICM 2013

20 ARDS in HIV positive patients HIV positive patients: - younger - APACHE II - COPD, asthma - hospital acq. infection - prior sepsis Hospital mortality HIV vs. non HIV: 50 vs. 38.4%, p=0.19 HIV not an independent risk factor for hospital mortality Nirappil et al, J Crit Care 2014

21 ECMO in ARDS HIV + ARDS patients (n=8) age 28 (21-55) hospital survival 50% Ali et al. BMC Pulmonary Medicine 2016

22 Another example: Goodpasture Syndrome Ali et al. BMC Pulmonary Medicine 2016

23 Re-transplant after lung tx Re-transplant after lung tx (n=39) elective (n=23) ECMO intubated (n=11) awake ECMO (n=5) re-transplant rate (%) Wait list mortality (%) Periop mortality (%) year survival (%) year survival (%) Lang et al., J Heart Lung Transplant 2014

24 Re-transplant after lung tx - ECCO 2 R Transplant after ECCO 2 R bridging (n=20): 7 patients with re-transplant (terminal graft failure) 3 patients non-intubated at ECCO 2 R start, 2 extubated during ECCO 2 R 6 underwent retransplant Long-term survival in 6 out of 7 patients: 544 ( ) days Schellongowski et al., Transplant International 2015

25 Infection in IC patients on ECMO? 220 av ECMO patients: 64 patients (29%) IC (Cancer, AIDS, solid organ transplant, chemo, IS therapy) Infection at ECMO start more common in IC (35 vs. 19%, p=0.02) 142 (64%) with nosocomial infection during ECMO Nosocomial infection in IC patients not more often (OR 1.14 ( ), p= 0.46) Schmidt et al., Clin infect disease 2012

26 Infection in IC patients on ECMO? 15 hematologic vv ECMO patients with ARDS: All patients on broad-spectrum antibiotics, eight on additional antifungals 110 cultures (bal, blood, urine, catheters, stool, pleural/peric. effusion, lung Bx, wound swaps, CSF) only 6 were positive (catheter-related infection, n = 5; urinary tract infection, n = 1). Reactivation of CMV (n=1) and HSV (n=3) -> Infection screening +/- antibiotic prophylaxis are recommended by several authors Wohlfarth et al., Crit Care 2014

27 Identify the cause of acute respiratory failure!!! Azoulay et al., AJRCCM 2010

28 If (suspected) infectious: treat according to guidelines!!

29 After all: the level of evidence to support or disregard ECMO in immunocompromised patients are rather poor... Coming up: IDEA Study Retrospective observational approx. 250 immunocompromised patients ECMO Network / Matthieu Schmidt, Paris EFRAIM / ECLS Substudy (Elie Azoulay, Peter Schellongowski) Prospective registry on cancer patients (ichop) Interventional protocols?

30 Possible ECMO indications in immunocompromised patients Only patients with ICU full code status Only patients with therpeutic option with regard to organ failure Cancer patients: Masses / obstruction -> probably good indication (if therapeutic option) ARDS -> moderate prognosis (subgroups?) Prevention of intubation -> experimental Allo stem cell transplant -> restrictive Non-cancer patients: AIDS with ARDS -> no absolute contraindication Rheumatologic disease -> depending on the therapeutic option Solid organ translant -> depending on the therapeutic option

31 Specific considerations Aetiology -> do everything to identify!!! If infectious in hema pts. -> guidelines for (empiric) therapy > 1 organ failure -> no absolute contraindication Neutro-/ thrombopenia -> no absolute contraindication At risk of bleeding -> low or not anticoagulation Infection during ECMO -> incidence? prognostic? Pharmacokinetics / Chemo -> pragmatic approach peter.schellongowski@meduniwien.ac.at