Intensive Care Medicine

, Volume 39, Issue 2, pp 275–281 | Cite as

Predicting mortality risk in patients undergoing venovenous ECMO for ARDS due to influenza A (H1N1) pneumonia: the ECMOnet score

  • Federico PappalardoEmail author
  • Marina Pieri
  • Teresa Greco
  • Nicolò Patroniti
  • Antonio Pesenti
  • Antonio Arcadipane
  • V. Marco Ranieri
  • Luciano Gattinoni
  • Giovanni Landoni
  • Bernhard Holzgraefe
  • Gernot Beutel
  • Alberto Zangrillo
  • on behalf of the Italian ECMOnet



The decision to start venovenous extracorporeal membrane oxygenation (VV ECMO) is commonly based on the severity of respiratory failure, with little consideration of the extrapulmonary organ function. The aim of the study was to identify predictors of mortality and to develop a score allowing a better stratification of patients at the time of VV ECMO initiation.


This was a prospective multicenter cohort study on 60 patients with influenza A (H1N1)-associated respiratory distress syndrome participating in the Italian ECMOnet data set in the 2009 pandemic. Criteria for ECMO institution were standardized according to national guidelines.


The survival rate in patients treated with ECMO was 68 %. Significant predictors of death before ECMO institution by multivariate analysis were hospital length of stay before ECMO institution (OR = 1.52, 95 % CI 1.12–2.07, p = 0.008); bilirubin (OR = 2.32, 95 % CI 1.52–3.52, p < 0.001), creatinine (OR = 7.38, 95 % CI 1.43–38.11, p = 0.02) and hematocrit values (OR = 0.82, 95 % CI 0.72–0.94, p = 0.006); and mean arterial pressure (OR = 0.92, 95 % CI 0.88–0.97, p < 0.001). The ECMOnet score was developed based on these variables, with a score of 4.5 being the most appropriate cutoff for mortality risk prediction. The high accuracy of the ECMOnet score was further confirmed by ROC analysis (c = 0.857, 95 % CI 0.754–0.959, p < 0.001) and by an independent external validation analysis (c = 0.694, 95 % CI 0.562–0.826, p = 0.004).


Mortality risk for patients receiving VV ECMO is correlated to the extrapulmonary organ function at the time of ECMO initiation. The ECMOnet score is a tool for the evaluation of the appropriateness and timing of VV ECMO in acute lung failure.


Acute respiratory distress syndrome ECMO Extracorporeal membrane oxygenation H1N1 virus Mortality Multiple organ failure 



Members of the ECMOnet Italian ECMO network not included in the authors’ list: A.M. Scandroglio, M.G. Calabrò, T. Bove, M. De Bonis (Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy); G. Foti, M. Bombino (Department of Perioperative Medicine and Intensive Care, San Gerardo Hospital, Monza, Italy); A. Peris, G. Cianchi, A. Pasquini (Department of Anesthesiology and Intensive Care, Carreggi University Hospital, Firenze, Italy); A. Braschi, F. Mojoli (Department of Anesthesiology and Intensive Care I, IRCCS Policlinico San Matteo Foundation, University of Pavia, Italy); M. Zanierato (Department of Anesthesiology and Intensive Care I, IRCCS Policlinico San Matteo Foundation, Italy); G.A. Iotti, M. Belliato, L. Carnevale (Department of Anesthesiology and Intensive Care II, IRCCS Policlinico San Matteo Foundation, University of Pavia, Italy); P. Terragni, R. Urbino, L. Del Sorbo, V. Fanelli (Department of Anesthesia and Critical Care Medicine, University of Turin, S. Giovanni Battista-Molinette Hospital, Turin, Italy); G. Panarello (Department of Intensive Care, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy); M. Antonelli, G. Bello, R. Maviglia (Department of Anesthesiology and Intensive Care Medicine, Cattolica—Sacro Cuore University, Rome, Italy); A. Lissoni, S. Crotti (Department of Anesthesia, IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy); P. Pietropaoli, M. Rocco, A. Morelli (Department of Anesthesiology, Critical Care Medicine, and Pain Therapy, La Sapienza University, Rome, Italy); G. Frascaroli, F. Caramelli (Department of Cardio-thoraco-vascular Integrated Activities, S. Orsola-Malpighi University Hospital, Bologna, Italy); R. Tufano, M. Iannuzzi (Department of Anesthesiology, Resuscitation Care, Intensive Care, Hyperbaric Therapy, Pain Therapy, Federico II University, Naples, Italy); F. Bruno, S. Grasso (Anesthesiology and Intensive Care Unity, Department of Emergency Medicine and Organ Transplants, Bari University, Bari, Italy); L. Lorini (Department of Anesthesiology and Intensive Care, Ospedali Riuniti, Bergamo, Italy); C. Ori, S. Rossi, P. Persona (Institute of Anesthesiology and Intensive Care, University Hospital of Padua, Padua, Italy). The ECMOnet is a national network instituted by the Italian Ministry of Health in response to the 2009 H1N1 pandemic. The Italian Ministry of Health allocated all economic, human and technological resources required for the development and activity of the ECMOnet. Our study used the ECMOnet registry as the main data source. We did not receive funds from the Italian Ministry of Health for the present study. The analysis presented in this study was entirely supported by departmental funds. The authors had full control of primary data, and they agree to allow the journal to review their data if requested.

Supplementary material

134_2012_2747_MOESM1_ESM.doc (81 kb)
Supplementary material 1 (DOC 81 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2012

Authors and Affiliations

  • Federico Pappalardo
    • 1
    Email author
  • Marina Pieri
    • 1
  • Teresa Greco
    • 1
  • Nicolò Patroniti
    • 2
  • Antonio Pesenti
    • 2
  • Antonio Arcadipane
    • 3
  • V. Marco Ranieri
    • 4
  • Luciano Gattinoni
    • 5
  • Giovanni Landoni
    • 1
  • Bernhard Holzgraefe
    • 6
  • Gernot Beutel
    • 7
  • Alberto Zangrillo
    • 1
  • on behalf of the Italian ECMOnet
  1. 1.Department of Cardiac Anesthesia and Intensive CareVita-Salute San Raffaele UniversityMilanItaly
  2. 2.Department of Experimental MedicineUniversity of Milano Bicocca, San Gerardo HospitalMonzaItaly
  3. 3.Department of Anesthesia and Critical CareMediterranean Institute for Transplantation and Advanced Specialized TherapiesPalermoItaly
  4. 4.Department of Anesthesia and Critical Care MedicineUniversity of Turin, S. Giovanni Battista-Molinette HospitalTurinItaly
  5. 5.Department of AnesthesiaIRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of MilanMilanItaly
  6. 6.Department of Physiology and Pharmacology, ECMO Department Karolinska Astrid Lindgren Children′s HospitalKarolinska Institutet, Karolinska University HospitalSolnaSweden
  7. 7.Department of Hematology, Hemostasis, Oncology, and Stem Cell TransplantationHannover Medical School (MHH)HannoverGermany

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