Availability in ECMO Reduces the Failure to Rescue in Patients With Pulmonary Embolism After Major Surgery: A Nationwide Analysis of 2.4 Million Cases

Abstract

Objective: Postoperative pulmonary embolism (PE) is a rare but potentially life-threatening complication, which can be treated with extracorporeal membrane oxygenation (ECMO) therapy, a novel therapy option for acute cardiorespiratory failure. We postulate that hospitals with ECMO availability have more experienced staff, technical capabilities, and expertise in treating cardiorespiratory failure.

Design: A retrospective analysis of surgical procedures in Germany between 2012 and 2019 was performed using hospital billing data. High-risk surgical procedures for postoperative PE were analyzed according to the availability of and expertise in ECMO therapy and its effect on outcome, regardless of whether ECMO was used in patients with PE.

Methods: Descriptive, univariate, and multivariate analyses were applied to identify possible associations and correct for confounding factors (complications, complication management, and mortality).

Results: A total of 13,976,606 surgical procedures were analyzed, of which 2,407,805 were defined as high-risk surgeries. The overall failure to rescue (FtR) rate was 24.4% and increased significantly with patient age, as well as type of surgery. The availability of and experience in ECMO therapy (defined as at least 20 ECMO applications per year; ECMO centers) are associated with a significantly reduced FtR in patients with PE after high-risk surgical procedures. In a multivariate analysis, the odds ratio (OR) for FtR after postoperative PE was significantly lower in ECMO centers (OR, 0.75 [0.70-0.81], P < 0.001).

Conclusions: The availability of and expertise in ECMO therapy lead to a significantly reduced FtR rate of postoperative PE. This improved outcome is independent of the use of ECMO in these patients.

Keywords: ECMO; FtR; pulmonary embolism; surgery.

FIGURE 1.

Inclusion criteria as a flow chart (Supplemental Table 1, see http://links.lww.com/AOSO/A315 for OPS codes for primary identification and final inclusion of patient records, respectively). PE was identified by ICD code I26. ECMO application was defined by cases with OPS code 8-852.0 or 8-852.3. All patient records were complete.

FIGRUE 2.

Risk-adjusted ORs with 95% CI for in-hospital mortality. (A) According to patients’ age, (B) according to patients’ gender, and (C) according to hospitals’ ECMO experience. *P = 0.002, **P < 0.001 (logistic regression analysis).