Bilirubin elevation and outcomes in extracorporeal membrane oxygenation (ecmo) support

SESSION TITLE: ECMOre SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/10/2023 12:55 pm - 01:40 pm PURPOSE: Extracorporeal Membrane Oxygenation (ECMO) support is being employed with increasing frequency for patients with severe respiratory and/or cardiac failure. Elevations of serum bilirubin, sometimes to extremely high values, are commonly encountered when caring for patients on ECMO support. Several single center retrospective studies have described elevated bilirubin as associated with increased mortality in ECMO supported patients. In fact, one study cited a 90% mortality in patients with total serum bilirubin greater than 11 mg/dL. (ASAIO 2019; 65:812-818). We sought to systematically describe the experience with bilirubin elevation at our center in the ECMO population. METHODS: A retrospective chart review was performed on all adult patients supported with ECMO at Inova Fairfax Medical Center from January 1, 2018 to March 1, 2023. Patients were divided by support with venovenous (VV) or venoarterial (VA) ECMO. Patients were divided into three groups based on highest total serum bilirubin value following initiation of ECMO support: 0-3 mg/dL, 3-10 mg/dL, and > 10 mg/dL. In-hospital mortality was assessed for each group. RESULTS: A total of 527 adult patients were supported with ECMO during the specified timeframe (123 VV (23.3%), 404 VA (76.7%). The distribution of peak total serum bilirubin levels among patients was as follows: VV-ECMO – 0-3 mg/dl (82, 66.6%), 3-10 mg/dL (29, 23.6%), and >10 mg /dL (12, 9.8%); VA-ECMO - – 0-3 mg/dl (235, 58.2%), 3-10 mg/dL (113, 28.0%), and >10 mg /dL (56, 13.9%). In-hospital mortality amongst these groups was as follows: VV-ECMO – 0-3 mg/dl (10, 12.2%), 3-10 mg/dL (17, 58.6%), and >10 mg /dL (6, 50%); VA-ECMO – 0-3 mg/dl (81, 34.5%), 3-10 mg/dL (57, 50.4%), and >10 mg /dL (41, 73.2%). The highest total bilirubin in a VV-ECMO survivor was 14.8 mg/dL, while the highest total bilirubin in a VA survivor was 46.3 mg/dL. Eight of twenty-four (33.3%) VA ECMO patients with total bilirubin over 20 mg/dL survived their hospitalization. No patients appeared to have fulminant hepatic failure despite elevations of serum bilirubin. CONCLUSIONS: Elevations of bilirubin are commonly encountered in patients on ECMO support and appear to be associated with increased mortality. Further survival analysis controlling for additional clinical characteristics is warranted. Despite the association between bilirubin and mortality it does not appear that deaths are due to liver disease and elevations in bilirubin may be more reflective of overall clinical status. CLINICAL IMPLICATIONS: Elevations of bilirubin seem to carry prognostic significance in ECMO but should not be solely relied upon to make decisions regarding ongoing extracorporeal support. DISCLOSURES: No relevant relationships by Robert Brammer No disclosure on file for Jessica Buchner No relevant relationships by Abhimanyu Chandel No disclosure on file for Junad Chowdhury No disclosure on file for Mehul Desai No disclosure on file for Jessica Gibson Speaker relationship with United Therapeutics Please note: 2021 -present Added 03/30/2023 by Christopher King, source=Web Response, value=Consulting fee No relevant relationships by James Lantry No disclosure on file for Girish Majeti No relevant relationships by Patrick Moran No relevant relationships by Veronica Nguyen No relevant relationships by Mitchell Psotka No disclosure on file for Christopher Quinn No relevant relationships by Carolyn Rosner No disclosure on file for Jikerkhoun Simou No relevant relationships by Ramesh Singh No disclosure on file for Patrick Stone No relevant relationships by Zachary Stotz No relevant relationships by Daniel Tang