Original ArticleAutopsy and clinical discrepancies in patients undergoing extracorporeal membrane oxygenation: a case series☆,☆☆
Introduction
Extracorporeal membrane oxygenation (ECMO, also known as extracorporeal life support) is a form of advanced life support in which venous blood is taken from the patient and pumped through an external artificial circuit to a membrane lung (or oxygenator), where carbon dioxide is removed and oxygen is added to the blood. The blood is then returned to the patient's venous or arterial circulation. Venovenous (VV) ECMO is used to provide gas exchange support for patients with severe respiratory failure refractory to conventional ventilatory support. Venoarterial (VA) ECMO is used to provide both circulatory and gas exchange support for patients with severe cardiac failure refractory to inotropic support. Venous blood from the patient is accessed from the large central veins and returned to the arterial system in the ascending aorta (central VA ECMO) or a peripheral artery (femoral, carotid, or axillary artery, referred to as peripheral VA ECMO). Patients who need salvage ECMO therapy are often very unstable and are generally managed under heavy sedation, at least initially. Developments in cardiopulmonary bypass machinery with newer pump technologies, better cannulation techniques, and improvised management guidelines have resulted in better survival of ECMO patients in recent years [1]. However, there are limited data addressing discrepancies between pre- and postmortem findings in patients undergoing ECMO.
Autopsy remains an important tool for assuring and improving the quality of medical care by monitoring the diagnostic accuracy and treatment of patients. Although the possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, it remains sufficiently high that some of the reversible clinical conditions remain undiagnosed when the patient is critically ill and heavily sedated [2]. Early detection and active treatment for these previously missed diagnoses and complications may have a significant impact on the patients' mortality and morbidity. Despite the presence of publications reporting the discrepancies between clinical findings and autopsy reports [2], [3], autopsy rates have been declining worldwide over the past few decades [4], [5].
Previous studies reporting the discrepancy between clinical findings and autopsy reports in pediatric ECMO patients have been published in the literature, while analytical studies in adult ECMO patients were rarely found. The aims of this study were to investigate discrepancies between clinical and autopsy findings in patients placed on ECMO at our institution and to assess the value of autopsy in these patients.
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Study design and patient population
This retrospective single-center observational study was conducted on deceased ECMO patients who underwent autopsy examination from 2004 through 2015 in our institution. After institutional review board approval, clinical and autopsy details of these patients were obtained from our institutional ECMO database and the hospital medical records. All adult patients who were admitted on ECMO to the intensive care unit were included in the study. In accordance with local laws, we referred all
Results
Of the 122 patients who received ECMO between 2004 and 2015, 53 (43.4%) adult patients died on ECMO; all of them were referred for autopsy. Nineteen adult patients had autopsy performed. There were 19 patients included in our analysis; 13 of them were males. The mean age of the patients was 47.1 years, and the mean duration of ECMO was 12.5 days. The demographics of our patients are shown in Table 2. Eighteen patients received VA ECMO for a primary cardiac cause, while one received VV ECMO for
Discussion
Our results demonstrate that autopsies are valuable in patients who underwent ECMO as all the patients in our analysis had at least one major discrepancy between the clinical findings and autopsy reports. The major clinical discrepancies were significant, implying that fatal near misses are common and recognition of clinical signs could be challenging in patients who are deeply sedated during ECMO. Patients also had an average of more than seven major critical events (class I or class II
Conclusions
In conclusion, we found major discrepancies between premortem and postmortem diagnoses in patients who underwent ECMO. Our findings highlight the possible difficulties in clinically diagnosing events on ECMO. Low threshold for investigations coupled with improved scrutiny and better diagnostic techniques in ECMO patients might enhance lesser discrepancies and better outcomes in ECMO patients. The use of newer advanced beside investigations and monitoring modalities may help to detect the
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