title: Extracorporeal life support in patients with refractory cardiogenic shock: keep them awake.
abstract: OBJECTIVE
  Traditionally, patients on extracorporeal life support (ECLS) are sedated and mechanically ventilated and therefore prone to complications related to immobility and ventilation. We adopted this 'Awake ECLS' strategy for the patients with refractory cardiogenic shock (RCS) as a bridge to decision.
  
  
  METHODS
  Sixty-eight patients with RCS were supported by ECLS (All veno-arterial) in years 2010-2014. Patients that could not survive 24 h after ECLS implantation (9 patients) were excluded from the study. Study population constituted 59 patients-'Awake' group (n = 18; maintained awake without intubation) and 'Control' group (n = 41; intubated and required mechanical ventilation).
  
  
  RESULTS
  Nine (50%) patients were awake at implantation, with 5 of them remaining free of sedation and ventilator support through to explantation. Nine patients were ventilated at the time of implantation but subsequently extubated and remained non-intubated and ventilator free. Post-ECLS survival at 1 month was 78 and 42% while the survival to discharge was 78 and 37% in awake and control group, respectively.
  
  
  CONCLUSIONS
  ECLS as a bridge to decision in RCS is effective in restoring adequate systemic perfusion and recovering end-organ function. ECLS can be initiated in awake patients with RCS and patients can be awakened on ECLS. The 'awake ECLS' strategy may avoid complications related to mechanical ventilation, sedation and immobilization. RCS patients supported on ECLS without severe metabolic acidosis, multiorgan failure, intra-aortic balloon pump or uncertain neurological status are more likely to be weaned from the ventilator. Patients that are awake at the time of ECLS implantation are more likely to remain awake during ECLS.
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK drprashantis@rediffmail.com.
authors: Prashant N
authors: PN
authors: Mohite
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Sundeep
authors: S
authors: Kaul
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Anton
authors: A
authors: Sabashnikov
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Naufal
authors: N
authors: Rashid
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Javid
authors: J
authors: Fatullayev
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Bartlomiej
authors: B
authors: Zych
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Aron-Frederik
authors: AF
authors: Popov
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Olaf
authors: O
authors: Maunz
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Nikhil P
authors: NP
authors: Patil
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Diana
authors: D
authors: Garcia-Saez
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Fabio
authors: F
authors: DeRobertis
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Toufan
authors: T
authors: Bahrami
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Mohamed
authors: M
authors: Amrani
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Nicholas R
authors: NR
authors: Banner
authors: Department of Cardiothoracic Transplantation and Mechanical Support, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors: Andre R
authors: AR
authors: Simon
mesh_terms: D000328:Adult; D060666:Airway Extubation; D005112:Extracorporeal Circulation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007103:Immobilization; D007442:Intubation, Intratracheal; D053208:Kaplan-Meier Estimate; D008020:Life Support Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D020127:Recovery of Function; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D015300:Ventilator Weaning; D014851:Wakefulness
chemical_list: D006993:Hypnotics and Sedatives
keywords: Awake extracorporeal life support; Extracorporeal membrane oxygenator; Mechanical ventilation; Refractory cardiogenic shock