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Characterizing the Racial Discrepancy in Hypoxemia Detection in Venovenous Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis

  • RESEARCH
  • EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)
  • Published:
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Abstract

Purpose

Skin pigmentation influences peripheral oxygen saturation (SpO2) compared to arterial saturation of oxygen (SaO2). Occult hypoxemia (SaO2 ≤ 88% with SpO2 ≥ 92%) is associated with increased in-hospital mortality in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO2-SaO2 discrepancy due to significant hemolysis.

Methods

Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO2 and SaO2 measurements from over 500 centers in the Extracorporeal Life Support Organization Registry (1/2018–5/2023) were included. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO2-SaO2 calculations.

Results

Of 13,171 VV-ECMO patients, there were 7772 (59%) White, 2114 (16%) Hispanic, 1777 (14%) Black, and 1508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% (N = 233). Occult hypoxemia was more common in Black and Hispanic patients versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively). In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18–2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95% CI = 1.16–2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95% CI = 1.15–2.55, P = 0.008) had higher risk versus White patients. Higher pump flow rates (aOR = 1.29, 95% CI = 1.08–1.55, P = 0.005) and on-ECMO 24-h lactate (aOR = 1.06, 95% CI = 1.03–1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia.

Conclusion

SaO2 should be carefully monitored if using SpO2 during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia.

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Abbreviations

ABG:

Arterial blood gas

aOR:

Adjusted odds ratio

AUC:

Area under the receiver-operating characteristic curve

CI:

Confidence interval

COVID-19:

Coronavirus Disease 19

ECMO:

Extracorporeal membrane oxygenation

ELSO:

Extracorporeal Life Support Organization

IQR:

Interquartile range

PaO2 :

Partial pressure of oxygen

ROC:

Receiver-operating characteristic

SaO2 :

Oxygen saturation measured by arterial blood gas

SpO2 :

Oxygen saturation measured by pulse oximetry

SD:

Standard deviation

tMCS:

Temporary mechanical circulatory support

VV-ECMO:

Venovenous ECMO

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Funding

SPK is supported by NHLBI (5K08HL14332). SMC is supported by NHLBI (1K23HL157610).

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Authors and Affiliations

  1. Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Andrew Kalra, Sari D. Holmes, Glenn J. R. Whitman & Sung-Min Cho

  2. Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA

    Andrew Kalra

  3. Department of Critical Care, Mercy Hospital of Buffalo, Buffalo, NY, USA

    Christopher Wilcox

  4. Division of Cardiothoracic Surgery, Department of Surgery and Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, 84132, USA

    Joseph E. Tonna

  5. Department of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea

    In Seok Jeong

  6. Extracorporeal Life Support Organization, Ann Arbor, MI, USA

    Peter Rycus

  7. Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA

    Marc M. Anders

  8. Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA

    Akram M. Zaaqoq

  9. Cardiothoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands

    Roberto Lorusso

  10. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Daniel Brodie, Steven P. Keller & Bo Soo Kim

  11. Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA

    Sung-Min Cho

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  1. Andrew Kalra
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Contributions

A.K. contributed to Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, and Visualization. C.W. contributed to Writing – original draft, Writing – review & editing, and Visualization. S.D.H. contributed to Validation, Formal analysis, Investigation, Visualization, Writing – original draft, and Writing – review & editing. J.E.T. contributed to Validation and Writing – review & editing. I.S.J. contributed to Validation and Writing – review & editing. P.R. contributed to Data curation and Writing – review & editing. M.A. contributed to Data curation and Writing – review & editing. A.M.Z. contributed to Data curation and Writing – review & editing. R.L. contributed to Validation and Writing – review & editing. D.B. contributed to Validation and Writing – review & editing. S.P.K. contributed to Validation, Writing – review & editing, and Funding acquisition. B.S.K. contributed to Validation and Writing – review & editing. G.J.R.W. contributed to Conceptualization, Methodology, Resources, Writing – review & editing, Visualization, Supervision, and Project administration. S.M.C. contributed to Conceptualization, Methodology, Investigation, Resources, Writing – review & editing, Visualization, Supervision, Project administration, and Funding acquisition.

Corresponding author

Correspondence to Sung-Min Cho.

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Conflict of Interest

Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23HL141596). Dr. Tonna is the Chair of the Registry Committee of the Extracorporeal Life Support Organization (ELSO). Dr. Brodie receives research support from and consults for LivaNova. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, Inspira, and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organization (ELSO) and the Chair of the Executive Committee of the International ECMO Network (ECMONet) and he writes for UpToDate. Dr. Lorusso is a consultant for Medtronic, LivaNova, Getinge, and ASbiomed and Member of the Medical Advisory Board of Eurosets and Xenios. He is the ELSO Research Committee Chair, and Honorary Secretary of EuroELSO. The authors do not have any additional conflicts of interest to declare.

IRB Approval

This study was approved by the Johns Hopkins Hospital Institutional Review Board (IRB00216321) on 10/22/2019. The study title is “Retrospective Analysis of Outcomes of Patients on Extracorporeal Membrane Oxygenation.” All procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975.

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Publication History: This manuscript was uploaded to the preprint server “Research Square” with the following DOI: https://doi.org/10.21203/rs.3.rs-3617237/v1.

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Kalra, A., Wilcox, C., Holmes, S.D. et al. Characterizing the Racial Discrepancy in Hypoxemia Detection in Venovenous Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis. Lung (2024). https://doi.org/10.1007/s00408-024-00711-4

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