Only a third of patients are alive without moderate-to-severe disability at six months after initiation of extracorporeal membrane oxygenation (ECMO), Australian research shows.

The finding, from a Monash University-led registry study in 2019-2020, suggests the need for strategies such as rehabilitation during ECMO as well as ongoing support to help reduce disability and improve outcomes.

Published in Lancet Respiratory Medicine [link here], the study comprised 442 adult patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during an ICU stay at one of 23 public or private hospitals.

It found the primary composite outcome of death or moderate-to-severe disability – WHO Disability Assessment Schedule (WHODAS) ≥ 25% – occurred in 66% of patients overall.

Death or disability was numerically higher in patients who received extracorporeal CPR (82%) than in those who received veno-arterial ECMO (67%) or veno-venous ECMO (54%).

After multivariable analysis, the incidence of death or disability at six months was significantly higher in patients who received eCPR than VV-ECMO but not higher than for VA-ECMO.

Secondary outcomes including ICU mortality, hospital mortality, and 90-day and 180-day mortality were higher in the eCPR group than in the other groups.

Deaths between enrolment and follow-up at 6 months occurred in 45% of the cohort – 48% of VA-ECMO patients, 28% of VV-ECMO patients, and 70% of eCPR patients.

“Among the survivors, 62 (32%) of 193 reported disability at 6 months, which was similar for all ECMO types,” the study authors said.

“Physical, psychological, and cognitive functioning were adversely affected at 6 months and new disability was reported in 61 (37%) of 165 surviving patients.”

“Overall, the severity of disability… increased from pre-hospital to 6 months after initiation of ECMO (OR 2·33 [95% CI 1 ·79–3·03]; p<0·0001) and remained significant after multivariable adjustment (OR 2·13 [1·42–3·18]; p=0·0002). However, there were some patients who had reduced their degree of disability at 6 months.”

The study, led by Professor Carol Hodgson from the ANZ Intensive Care Research Centre at Monash, also found the severity of disability increased regardless of the type of ECMO.

A quarter of survivors (25%) who were employed before hospital admission were subsequently unemployed owing to their health at six months.

“Of note, there was no change overall in health-related quality of life, although more than 25% of survivors reported new problems in the EQ-5D-5L domains of mobility and pain.”

“Factors that could affect health-related quality of life include resilience, adaptation, post-traumatic growth after life-changing critical illness, and the environment.”

The study showed risk factors for death or disability at six months after ECMO included older age, higher illness severity, more organ failure, a cardiac arrest and diabetes pre-ECMO.

Heavier sedation, higher oxygen requirements and a higher lactate in the first 24 hours of ECMO were also associated with death or disability.

“This study provides valuable insights that could inform our management of these patients – for example, regarding the allocation of resources and selection of patients for ECMO based on their 6-month prognosis.”