Download Costs Associated with Extracorporeal Life Support Used in Adults: A

Costs of Adult ECLS
Original Article
Acta Cardiol Sin 2011;27:221-8
Medical Economics
Costs Associated with Extracorporeal Life
Support Used in Adults: A Single-Center Study
Yuan-Hsi Tseng,1 Meng-Yu Wu,1 Feng-Chun Tsai,1 Hai-Jing Chen2 and Pyng Jing Lin1
Background: To identify predictors of the total hospital costs associated with adult extracorporeal life support
(ECLS).
Methods: This retrospective study included 72 adults receiving ECLS for postcardiotomy cardiogenic shock,
non-postcardiotomy cardiogenic shock or arrest, and adult respiratory distress syndrome in a single institution
between January 2008 and December 2009. Data pertaining to the total hospital costs borne by these patients at a
single institution, including pre- and post-ECLS hospital stay and procedures, were obtained and compared for
patients who received ECLS for different indications and had different outcomes.
Results: Forty-six patients were weaned off ECLS, and 31 survived to hospital discharge. The mean durations of
ECLS and hospital stay were 173 hours and 50 days, respectively. The 2-year survival rate was 96.3% in discharged
patients without major squeal. The mean and median of the estimated total hospital costs were 39,845 USD and
39,262 USD, respectively. Personnel (41%) and blood product (8%) accounted for 50% of the total hospital costs.
Calculated using the multiple linear regression, the prediction model of the ECLS-associated costs was as follows:
total hospital cost (USD) = 20,514 + 314 ´ Total hospital stay (d) + 11,107 ´ In-hospital mortality - 7,343 ´
Non-postcardiotomy ECLS-assisted resuscitation (R2 = 0.43).
Conclusion: The length of hospital stay and occurrence of in-hospital mortality were predictors of the total hospital
costs associated with adult ECLS. Therefore, strategies that may contribute to the final success of ECLS, such as
actively including the good-prognostic candidates, should be adopted.
Key Words:
Cost analysis · Extracorporeal cardiopulmonary resuscitation (ECPR) · Extracorporeal life
support (ECLS) · Extracorporeal membrane oxygenation (ECMO)
INTRODUCTION
Studies focusing on ECLS in the past suggest that conventional indications for ECLS in adults include: (i)
acute heart failure due to postcardiotomy cardiogenic
shock (PCS), viral myocarditis, or some surgically manageable diseases such as acute myocardial infarction,
pulmonary embolism, and valvular dysfunction;1-3 and
(ii) adult respiratory distress syndrome (ARDS) refractory to lung-protective ventilation.4 However, new indications for ECLS are continuously being explored, particularly in the field of emergency medicine. ECLSassisted cardiopulmonary resuscitation (ECPR) 5 and
ECLS in traumatic ARDS (lung contusion) 6 are new
breakthroughs that have shown positive outcomes. However, ECLS is a resource-intensive therapy.7 Traditionally, the basic team required for providing ECLS com-
Extracorporeal life support (ECLS) is an effective
therapy for acute but potentially reversible cardiopulmonary dysfunction in modern critical care medicine.
Received: September 23, 2010 Accepted: April 26, 2011
1
Department of Cardiovascular Surgery, Chang Gung Memorial
Hospital and Chang Gung University, Taoyuan; 2Department of
Management Sciences and Decision Making, Yu Da University,
Miao-Li, Taiwan.
Address correspondence and reprint requests to: Dr. Pyng Jing Lin,
Division of Cardiovascular Surgery, Chang Gung Memorial Hospital,
No. 5, Fushing Street, Gueishan Shiang, Taoyuan 333, Taiwan.
Tel: 886-3-328-1200, ext. 2118; Fax: 886-3-328-5818; E-mail:
[email protected]
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Yuan-Hsi Tseng et al.
(n = 16) or cardiogenic shock (n = 2), or pulmonary support in advanced ARDS (n = 8) were indications for
ECLS. The study protocol was approved by the institutional review board.
prises cardiac surgeons, perfusionists, and members of
the intensive care unit. Multi-organ dysfunction due to
transient cardiopulmonary collapse (the post-cardiac arrest syndrome)8 or infection is the cardinal problem in
patients placed on ECLS; therefore, effective collaboration among the ECLS team with highly skilled professionals from multiple departments is crucial for achieving a successful outcome. Hence, to shorten the learning
curve and reduce expenses incurred during trial-anderror methods, ECLS is limited to tertiary centers in
some advanced western countries.7,9 On the basis of a recent study on adult ECLS conducted in Norway, 7 in
which the successful ECLS weaning rate was 57%
(8/14) and the mean hospital stay was 51 days, it was
found that the total hospital costs associated with adult
ECLS was 213,246 USD. Furthermore, the costs of personnel use (81%) and blood products (7%) accounted for
most of the total hospital costs. In Taiwan, the universal
health insurance program has covered the costs of ECLS
since 2003, and ECLS can be provided in all institutions
that have a basic ECLS team. With the help of the
government, a large number of valuable ECLS experiences have been gained and reported.10,11 Nevertheless,
the financial burden on universal health insurance providers may increase with extensive use of this resourceintensive therapy. To provide ECLS more efficiently, we
analyzed the structure and predictors of total hospital
costs associated with adult ECLS at a tertiary center in
Taiwan.
ECLS techniques
The details of our ECLS technique and therapeutic
protocols have been described previously. 6,12-14 The
venoarterial (VA), venovenous (VV), or combined mode
of ECLS (veno-venoarterial or veno-arteriovenous) was
applied to patients requiring predominant cardiac, pulmonary, or cardiopulmonary support. We used the
Capiox EBS system (Terumo, Tokyo, Japan) and the
Medos Deltastream system (Medos, Aachen, Germany)
to perform ECLS in this study. A hollow fiber oxygenator (Hilite LT 700; Medos) or a silicone oxygenator
(Medtronics, Minneapolis, MN, USA) was incorporated
into the ECLS circuit. The initial ECLS flow was set to
the maximum to maintain a stable hemodynamic profile
(mean arterial pressure, ³ 70 mmHg; heart rate, 60-100
beats/s without ventricular arrhythmia; urine output, ³
0.5 mL × kg -1 × h -1 ). The arterial oxygen saturation in
patients was maintained at ³ 95% in cardiac support and
³ 85% in pulmonary support. The fractional inspired
oxygen (FiO2) concentration for ECLS was set to 100%,
and the gas flow was adjusted according to the results of
the arterial blood gas analysis. Once the spontaneous circulation was restored by ECLS, imaging studies (computed tomography or coronary catheterization) were performed and definite treatments (coronary revascularization or other surgical procedures) were provided to
patients who experienced pre-ECLS shock because of
undetermined causes. Patients on ECLS were treated
with continuous heparin infusion (heparin would be held
temporarily if there was a risk of bleeding) and moderate
sedation. Inotropic agents or mechanical ventilation was
downregulated (tidal volume, FiO2, inspiratory pressure,
and positive end-expiratory pressure) to provide relief to
the patient’s heart or lungs. The oxygenator, combined
with the centrifugal pump, was replaced if the partial
pressure of oxygen in the post-oxygenated blood was
less than 200 mm Hg, or if significant hemolysis appeared. We attempted to wean patients off the ECLS if
there was evidence of cardiac or pulmonary recovery
after 3-7 days of support. Termination of ECLS was
suggested for unconscious patients (coma scale score, 3)
MATERIALS AND METHODS
Patient characteristics
Between January 2008 and December 2009, 74 consecutive adult patients (mean age, 56 ± 18 years) were
on ECLS for acute cardiopulmonary failure at our institution, and 72 were included in the present study. Two
patients who received ECLS because of postoperative
myocardial infarction and pneumonia after extensive
surgeries for head and neck cancers were excluded from
this cost-evaluating study, to exclude the additional costs
of anticancer therapies. In the present study, postcardiotomy cardiac support (PCS; n = 46), ECLSassisted resuscitation (including ECPR) in patients with
potentially reversible non-postcardiotomy cardiac arrest
Acta Cardiol Sin 2011;27:221-8
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Costs of Adult ECLS
service were combined as one personnel fee. All costs
were calculated according to the value of the New Taiwan Dollar (NTD) in 2010 and converted to US dollars
(USD) at the following exchange rate: 1 USD = 32
NTD.
Patients were grouped according to their ECLS indications (PCS, ECLS-assisted non-postcardiotomy cardiac resuscitation, and ARDS) and outcomes (died on
ECLS, weaned off ECLS but failed to survive to hospital
discharge, and weaned off ECLS with surviving to hospital discharge). Patients who had their ECLS discontinued due to futility were entered into the group “died
on ECLS.” Comparisons of total hospital costs were
made between different groups and a prediction model
of the total hospital costs associated with adult ECLS
was investigated. The short-term survival after hospital
discharge was also investigated. Statistical analyses were
performed using SPSS for Windows (Version 12.0;
SPSS Inc., IL, USA). Data were presented as the mean
or median for the numerical variables and as percentages
for the categorical data. Comparisons between different
groups were performed by the Kruskal-Wallis one-way
ANOVA test (with the Holm’s step-down procedure for
post-hoc test), 15 the Mann-Whitney U test, and the
with proven brain damages after 48-72 hours. Figures 1
and 2 depict our therapeutic protocols in adult cardiac
and pulmonary ECLS, respectively.
Data collection and analysis
The total hospital costs, determined from patient
records and time-motion studies as described by the
previous study,7 included all registered costs generated
during the pre- and post-ECLS period of a patient’s
admission. Because all patients received ECLS at our
institution, only the costs incurred at this tertiary center
were considered for analysis. The total hospital costs
were then subdivided into the costs related to personnel
use, blood products, lab and radiological examinations,
disposable items (including devices used during the
operation), medications, and renal dialysis. To simplify
the process of cost estimation, fees for diagnosis, ward
service, nursing techniques, medical managements, surgeries, anesthesia, rehabilitation, and pharmaceutical
Figure 2. The therapeutic protocol of pulmonary extracorporeal life
support (ECLS). *Re-circulation is acceptable when partial pressure of
the oxygen in the pre-oxygenator blood is less than 10% of the
post-oxygenator blood of ECLS. **The partial pressure of the oxygen in
the post-oxygenator blood is acceptable if it is > 200 mmHg under an
inflow of pure oxygen to the oxygenator.
Figure 1. The therapeutic protocol of cardiac extracorporeal life
support (ECLS). *Patients with postcardiotomy shock and failure to
wean from cardiopulmonary bypass. **Patients with cardiac arrest due
to uncertain causes.
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Yuan-Hsi Tseng et al.
Estimations of the total hospital cost
The mean and median values for the total hospital
costs, including the duration of stay and the procedures
used before and after ECLS, were 39,845 USD (SD,
18,911) and 39,262 USD (range, 2,263-88,527), respectively. A break-up of the total hospital costs showed that
the costs spent on personnel constituted 41%; blood
products, 8%; lab and radiology tests, 10%; disposable
items, 26%; medications, 13%; and renal dialysis, 2%.
Table 1 gives the demographics, durations, outcomes,
and total hospital costs among patients with different indications for ECLS. Table 2 illustrates distributions of
the total hospital costs and the components among
patients with different outcomes. The variables of the
derived prediction model of the total hospital costs associated with adult ECLS are demonstrated in Table 3 and
the formula was expressed as follows: total hospital cost
(USD) = 20,514 + 314 ´ Total hospital stay (d) + 11,107
´ In-hospital mortality - 7,343 ´ Non-postcardiotomy
ECLS-assisted resuscitation. The formula illustrated a
clinical scenario: the total hospital costs tended to increase for patients who had a long hospital stay, were
placed on ECLS for PCS or ARDS, and had in-hospital
mortality. Figure 4 shows the scatter plot of the observed
value to the predicted value of total hospital cost.
Chi-square test. The multiple linear regression method
with stepwise variable-selection was used to develop the
prediction model of the total hospital costs. The
Kaplan-Meier method was used to calculate the survival
curve for the cohort. The end-point for survival analysis
was death after hospital discharge, due to any reason. In
all tests except for the post-hoc analyses, the statistical
significance was set at p < 0.05.
RESULTS
ECLS courses and results
The total weaning rate was 64% (46/72), and the
survival to hospital discharge rate was 43% (31/72). For
all patients, the average duration of ECLS was 173 hours
(range, 6-576 h). The mean length of hospital stay was
50 days (range, 1-201 d). Thirty-three patients required
renal dialysis because of acute (n = 28, 5 from the ARDS
group) or chronic (n = 5, all from the PCS group) renal
failure. Fourteen patients in the ECLS-assisted nonpostcardiotomy resuscitation group received definite
treatments (8 coronary revascularizations, 3 pulmonary
endarterectomies, 2 cardiac valve replacements, and 1
heart transplant). The mean pre-ECLS mechanical ventilation time in the ARDS group was 106 hours (range,
43-255 h). The mean pre-ECLS CPR duration for the 16
patients in the ECLS-assisted non-postcardiotomy resuscitation group was 42 min (range, 20-75 min). Other
specific procedures on ECLS included surgical decompression of intracranial hematoma (n = 3), plasmapheresis or molecular adsorbents recirculating system
(MARS) for removing excessive auto-antibodies or bilirubin in serum (n = 2, the fees not included in health
insurance), and an exploratory laparotomy in a patient
with persistent gastrointestinal bleeding in whom the
bleeding source could not be identified and managed by
repeated endoscopies and angiographies. Significant
brain damage (mostly hypoxic encephalopathy) was
identified in 10 patients (9 in the ECPR group), and 5 of
these patients were taken off ECLS because of futility.
Finally, 15 of the 46 weaned patients died without hospital discharge. Causes of mortality in these 15 patients
were ventricular arrhythmia (n = 3), profound cerebral
dysfunction (n = 2), and sepsis with multiple organ failure (n = 10).
Acta Cardiol Sin 2011;27:221-8
Survival after hospital discharge
In the 31 patients who survived until hospital discharge, 4 were dependent on mechanical ventilation and
transferred to local institutions for long-term care. Of the
4 patients, 3 had significant neurological squeals and 1
had severe heart failure and was not suitable for heart
transplant. All of these patients were lost to follow-up.
One 81-year-old man later died at 3 months post discharge due to prosthetic valve endocarditis. The mean
follow-up times of the 27 patients were 12.7 months
(range, 3-24 m). The 2-year survival rate of these patients was 96.3%, as noted in the Figure 3 survival
curve.
DISCUSSION
This study aimed to evaluate the economic impacts
of adult ECLS, an advanced but resource-intensive life
support, in a developing Asian country that provides a
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Costs of Adult ECLS
Table 1. Demographics, details of extracorporeal life support (ECLS), and total hospital costs in patients on ECLS for different
reasons. Continuous data is presented as the mean (median)
Non-postcardiotomy
ECLS-assisted resuscitation
n = 18
Age (years)
Disease
Postcardiotomy shock
n = 46
ARDS
n=8
47 (45)
60 (63)
49 (45)
Acute myocardial infarction (8)
CABG (18)
Pneumonia (6)
Pulmonary emboli (3)
Valve (13)
Atypical (2)
Acute viral myocarditis (2)
CABG-combined valve (11)
Bacterial (3)
Acute valvular dysfunction (2)
Aortic surgery (3)
Lung contusion (2)
Electric burn (1)
Heart transplant (1)
Intra-abdominal sepsis (1)
Sepsis with unknown origin (2)
ECLS mode
Venoarterial
Venovenous
Venoarterial-Venovenous
Total ECLS Duration (h)
Total Hospital stay (d)
Outcome
Died on ECLS
Weaned without surviving to discharge
Weaned with surviving to discharge
Estimated total hospital cost (USD)
18 (100%)
0
0
209 (144)
35 (27)
44 (96%)
1 (2%)
1 (2%)
147 (120)
56 (47)
0
7 (89%)
1 (11%)
243 (271)
48 (33)
10 (56%)
03 (17%)
05 (27%)
28266 (27262)
11 (24%)
11 (24%)
24 (52%)
43245 (42445)
5 (63%)
1 (12%)
2 (25%)
46345 (43258)
Non-postcardiotomy ECLS-assisted resuscitation, patient receive ECLS due to non-postcardiotomy cardiogenic shock or arrest;
Postcardiotomy shock, cardiogenic shock after cardiac surgery; ARDS, adult respiratory distress syndrome; CABG, coronary artery
bypass grafting; Weaned without surviving to discharge, patients weaned off ECLS but failed to survive to hospital discharge;
Weaned with surviving to discharge, patients weaned off ECLS and survived to hospital discharge.
Table 2. Demographics and distribution of total hospital costs in patients with different outcomes. The continuous data is presented
as the mean (median)
Died on ECLS
(1)
n = 26
Weaned without Weaned with
Kruskal-Wallis
surviving to
surviving to
test
discharge (3)
discharge (2)
p (a = 0.05)
n = 31
n = 15
Age (years)
56 (57)
58 (66)
55 (58)
Total ECLS duration (h)
271 (192)
160 (144)
143 (96)0
Total hospital stay (d)
19 (16)
51 (56)
76 (63)
Total hospital cost (USD) 32112 (32239) 47682 (52424) 42537 (43495)
Personnel use (USD)
10129 (9068)0 21915 (23424) 19252 (16722)
Blood product (USD)
3766 (2251)
3206 (2860)
2295 (2077)
Radiological tests (USD)
214 (186)
523 (531)
745 (592)
Biochemistry tests (USD) 3051 (2712)
4121 (4381)
3787 (3751)
Medication (USD)
3310 (2807)
5890 (5850)
6122 (4529)
Disposable items (USD) 10947 (9156)0 10523 (10278) 10061 (9500)0
Dialysis (USD)
695 (323)
1504 (645)0
247 (0)00
0.88
0.25
< 0.0001*
0.016*
< 0.0001*
0.26
< 0.0001*
0.16
0.003*
0.75
< 0.0001*
Post-hoc test
(a = 0.017)**
p12 < 0.0001*; p23 = 0.11; p13 < 0.0001*
p12 = 0.015*; p23 = 0.14; p13 = 0.033
p12 < 0.0001*; p23 = 0.30; p13 < 0.0001*
p12 < 0.0001*; p23 = 0.34; p13 < 0.0001*
p12 = 0.004*; p23 = 0.72; p13 = 0.003*
p12 = 0.48; p23 < 0.0001*; p13 < 0.0001*
ECLS: extracorporeal life support. Weaned without surviving to discharge: Patients weaned off ECLS but failed to survive to
hospital discharge. Weaned with surviving to discharge: Patients weaned off ECLS and survived to hospital discharge.
*p < 0.05. **The p value of the post-hoc test is 0.017 (0.05 divided by 3, because the post-hoc test had been performed for the 3
different outcomes). p12: statistical significance of comparisons between patients who died when on ECLS and patients who were
weaned off ECLS but died in the hospital. p23: statistical significance of comparisons between patients who were weaned off ECLS
but died in the hospital and those who were weaned off ECLS and discharged. p13: statistical significance of comparisons between
patients who died when on ECLS and patients who were weaned off ECLS and were discharged.
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Yuan-Hsi Tseng et al.
Table 3. Multiple linear regression model of the total hospital cost in patients receiving extracorporeal life support (ECLS)
Variables
Intercept
Total hospital stay (d)
In-hospital mortality*
Non-postcardiotomy ECLS-assisted resuscitation*
Coefficient (b) Standard Error 95% confident interval T statistic
20514
00314
11107
-7343
4578
0047
4124
3628
11380 - 29649
220 - 408
02877 - 19336
-14583 - -10300
4.5
6.7
2.7
-2.0-
p value
< 0.0001
< 0.0001
0.009
0.047
* Binary variable. Value is “1” if the condition is true or “0” if the condition is false.
† The formula: Total hospital cost (USD) = 20,514 + 314 ´ Total hospital stay (d) + 11,107 ´ In-hospital mortality - 7,343 ´ Nonpostcardiotomy ECLS-assisted resuscitation.
‡ Multiple linear regression with stepwise method. R2: 0.43, adjusted R2: 0.41, F = 17.3, p < 0.0001.
Figure 3. The Kaplan-Meier survival curve of 27 of the 31 patients
who survived to hospital discharge.
Figure 4. The scatter plot of the observed value to the predicted value
of the total hospital cost. The regression line and lines presented as the
95% confident intervals of the predicted values are illustrated.
quality universal health insurance. The study was performed in a tertiary center, which had over 250 runs of
adult ECLS in the last 6 years, and the results should be
somewhat representative of the status quo in Taiwan.
Compared with the findings of the report from Norway,7
the total hospital costs associated with adult ECLS was
much lower (39,845 USD; between 2008 and 2009) in
Taiwan, due to the lower costs of the most important
consumptions of ECLS: medical personnel and blood
products. Therefore, different from conservative attitudes toward adult ECLS in western countries, using
ECLS to rescue adult patients suffering from acute
cardiopulmonary dysfunction is prevalent here and may
get adequate results when experienced groups of medical
professionals are involved.10,14
On the basis of the results of the current study, the
total hospital costs associated with adult ECLS were
found to be a function of the length of hospital stay,
indications of ECLS, and final outcomes. In general,
Acta Cardiol Sin 2011;27:221-8
total medical costs often increase sharply in the beginning of ECLS, and when major complications appear
that require special interventions. From this viewpoint,
adopting strategies that may have a shorter pre- or
post-ECLS hospital stay and a favorable outcome should
be very helpful in reducing the total hospital costs associated with adult ECLS. These strategies, such as the
CESAR criteria,9 often emphasize that candidates with
good prognosis should be actively included. The ability
to recognize potential ECLS candidates before they
experience obvious deterioration under conventional
therapy is very important to obtain these candidates with
“good prognosis” for ECLS. This ability will only be attained when the referring physicians and ECLS team
reach a sound consensus on the criteria for “unresponsiveness” to current intensive therapies.
Nevertheless, some patients may not recover and
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Costs of Adult ECLS
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3. Hsu PC, Lin TH, Lu YH, et al. Unprotected left main coronary
artery stenting under extracorporeal membrane oxygenation
support in a patient with high-risk acute myocardial infarction.
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4. Hemmila MR, Rowe SA, Boules TN, et al. Extracorporeal life
support for severe acute respiratory distress syndrome in adults.
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5. Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resuscitation
with assisted extracorporeal life-support versus conventional
cardiopulmonary resuscitation in adults with in-hospital cardiac
arrest: an observational study and propensity analysis. Lancet
2008;372:554-61.
6. Huang YK, Liu KS, Lu MS, et al. Extracorporeal life support in
post-traumatic respiratory distress patients. Resuscitation 2009;
80:535-9.
7. Mishra V, Svennevig JL, Bugge JF, et al. Cost of extracorporeal
membrane oxygenation: evidence from the Rikshospitalet University Hospital, Oslo, Norway. Eur J Cardiothorac Surg 2010;
37:339-42.
8. Neumar RW, Nolan JP, Adrie C, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison
Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada,
InterAmerican Heart Foundation, Resuscitation Council of Asia,
and the Resuscitation Council of Southern Africa); the American
Heart Association Emergency Cardiovascular Care Committee;
the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the
Council on Clinical Cardiology; and the Stroke Council. Circulation 2008;118:2452-83.
9. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic
assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory
failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-63.
10. Lan C, Tsai PR, Chen YS, et al. Prognostic factors for adult patients receiving extracorporeal membrane oxygenation as mechanical circulatory support -- a 14-year experience at a medical
center. Artif Organs 2010;34:E59-64.
11. Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resuscitation
with assisted extracorporeal life-support versus conventional
cardiopulmonary resuscitation in adults with in-hospital cardiac
arrest: an observational study and propensity analysis. Lancet
2008;372:554-61.
12. Wu MY, Lin PJ, Tsai FC, et al. Impact of preexisting organ dysfunction on extracorporeal life support for non-postcardiotomy
cardiopulmonary failure. Resuscitation 2008;9:54-60.
13. Wu MY, Lin PJ, Tsai FC, et al. Postcardiotomy extracorporeal life
support in adults: the optimal duration of bridging to recovery.
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may require organ (heart or lung) transplantation to survive. Because prolonged ECLS carries a high risk of
systemic thromboembolism and infection, the ability to
recognize “unresponsiveness” to ECLS is also important
to the ECLS team. Thus, establishing organized protocols with defined therapeutic targets should be helpful
in maximizing the effectiveness of this multidisciplinary
therapy within a short period.14 Finally, in patients with
severe brain damage, termination of ECLS after an intact
neurological prognostication around 72 h 8 of ECLS
should be considered to minimize ineffective therapies.
LIMITATIONS
The limitations of this study were the retrospective
design, moderate sample size, and considerable heterogeneity of the enrolled patients. The current model could
only partially explain the heterogeneity of the studied
sample. Further prospective studies to evaluate the costeffectiveness of adult ECLS among different etiologies
are required to establish better models and therapeutic
protocols.
CONCLUSION
ECLS is a practical therapy in countries that have
advanced critical care requirements and possess less
costly medical personnel. However, ECLS may have
high complication rates. Because the duration of hospital
stay and in-hospital mortality are predictors of costs associated with adult ECLS, strategies such as selecting
adequate candidates and using organized therapeutic
protocols should be adopted to improve clinical outcomes of ECLS, and to reduce the fees of ineffective
treatments when possible.
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