ECMO could involve mental health costs

A retrospective cohort study in Canada showed that the use of extracorporeal membrane oxygenation (ECMO) was associated with a modest increased risk of new mental health diagnoses in patients treated for critical illness in an intensive care unit (ICU).

Among adult survivors who received ECMO, the incidence of a new mental health diagnosis was 22.1 per 100 person-years compared with 14.5 per 100 person-years in ICU survivors who did not receive ECMO. reported Shannon M. Fernando, MD, MSc, of the University of Ottawa in Ontario, Canada, and colleagues a JAMA.

After weighting of propensity, use of ECMO for critical illness was significantly associated with an increased risk of new mental health diagnoses (HR 1.24, 95% CI 1.01-1.52), mainly depression, anxiety and trauma-related disorders.

“The use of ECMO has grown around the world, particularly in the context of the COVID-19 pandemic, where ECMO has been used for refractory respiratory failure in severe COVID-19 cases,” the researchers.

“Given the severity of the disease found among patients receiving ECMO, its invasive nature, as well as the prolonged duration of therapy and recovery that is often required among those who survive … survivors after ECMO may still be at risk. higher mental health downstream morbidity than other critically ill survivors, “they added.

Overall, the results of the ECMO in the context of the pandemic varied from “reasonable” to “exceptional”.

Of the secondary mental health outcomes assessed by Fernando and the team, ECMO and non-ECMO survivors had comparable rates per 100 person years for substance abuse (1.6 vs 1.4; HR 0.86, 95% CI 0.48 -1.53) and deliberate self-harm (0.4 vs 0.3; HR 0.68, 95% CI 0.21-2.23).

Furthermore, “there were fewer than five total cases of death by suicide in the entire cohort,” the group noted.

“As care providers, we can tell our patients that it’s common to struggle with their mental health after an ICU admission,” said co-author Peter Tanuseputro, MD, also of the University of Ottawa, in a statement. “ICU survivors need to realize that they often face months or years of recovery and that families and caregivers have to support them.”

In an accompanying editorial, Marieke Zegers, PhD, of Radboud University Medical Center in Nijmegen, The Netherlands, and colleagues noted that the study design only makes it “possible to speculate on the causal factors between ECMO and new mental health problems,” reiterating the biological mechanisms proposed by the study authors, including potentially increased susceptibility “to hypoxemia, shock and reduced oxygen supply that can predispose neurons to apoptosis and a higher risk of neurological complications such as ischemic stroke or delirium”.

The editorialists also pointed out that only pre-existing mental health diagnosis (HR 2.39, 95% CI 1.78-3.20) and an outpatient psychiatric visit during the year prior to ICU admission (HR 1.82 , 95% CI 1.25-2.65) were significantly associated with an increased risk of a new mental health diagnosis.

“This finding corroborates findings from previous studies that showed pre-ICU health status was the most important prognostic factor for mental health outcomes after ICU care and even suicide,” they wrote. “This suggests that ECMO treatment could be an additional trigger for mental problems in patients who are already vulnerable to mental health conditions.”

That “nearly half of the study population, including patients who received ECMO and those who did not, had at least one primary care or psychiatric mental health visit in the previous 5 years … raises the question whether the primary outcome truly reflected new mental health problems, “Zegers and the team added, noting that the primary finding persisted after the exclusion of patients with prior mental health diagnoses in a sensitivity analysis.

“We really need more research and investment in the area of ​​post-critical diseases,” said Fernando. “Patients will need help long after they leave the ICU.”

For this study, Fernando and colleagues followed 4,462 adults who were admitted to the ICU and survived hospital discharge from April 2010 to March 2020. Of these survivors, 642 had received ECMO (mean age 50.7 years, 40 , 7% women) and were followed for a median of 730 days; were matched with 3,820 ICU survivors who did not receive ECMO (mean age 51.0 years, 40.0% female), who were followed up for a median of 1,390 days.

The groups were matched for characteristics including age, gender, mental health history, critical illness severity, and length of hospital stay.

Of the 642 ECMO survivors, 37% were diagnosed with a new mental health condition.

The primary outcome was a composite of mood disorders, anxiety disorders, post-traumatic stress disorder, schizophrenia, other psychotic disorders, other mental health disorders, and social problems. The group also looked at eight secondary outcomes, including the incidence of substance abuse, deliberate self-harm, death by suicide, and individual components of the composite primary outcome.

Fernando and colleagues acknowledged that their study was observational and therefore cannot confirm a causal relationship between ECMO and downstream mental health effects.

The team is now gearing up to test a virtual treatment program for post-ICU syndrome, a collection of physical, mental and emotional symptoms that persist after an ICU admission.

  • Kate Kneisel is a freelance medical journalist based in Belleville, Ontario.

Disclosures

This study was funded by the Institut du Savoir Montfort, Hôpital Montfort in Ottawa, and supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health.

Fernando and Tanuseputro did not report any disclosures. The co-authors reported multiple relationships with government agencies, foundations and pharmaceutical companies.

The editorialists did not report any disclosures.

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