|
1
|
Grotberg JC, Reynolds D, Kraft BD. Extracorporeal Membrane Oxygenation for Respiratory Failure: A Narrative Review. J Clin Med 2024; 13:3795. [PMID: 38999360 PMCID: PMC11242398 DOI: 10.3390/jcm13133795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/20/2024] [Accepted: 06/23/2024] [Indexed: 07/14/2024] Open
Abstract
Extracorporeal membrane oxygenation support for respiratory failure in the intensive care unit continues to have an expanded role in select patients. While acute respiratory distress syndrome remains the most common indication, extracorporeal membrane oxygenation may be used in other causes of refractory hypoxemia and/or hypercapnia. The most common configuration is veno-venous extracorporeal membrane oxygenation; however, in specific cases of refractory hypoxemia or right ventricular failure, some patients may benefit from veno-pulmonary extracorporeal membrane oxygenation or veno-venoarterial extracorporeal membrane oxygenation. Patient selection and extracorporeal circuit management are essential to successful outcomes. This narrative review explores the physiology of extracorporeal membrane oxygenation, indications and contraindications, ventilator management, extracorporeal circuit management, troubleshooting hypoxemia, complications, and extracorporeal membrane oxygenation weaning in patients with respiratory failure. As the footprint of extracorporeal membrane oxygenation continues to expand, it is essential that clinicians understand the underlying physiology and management of these complex patients.
Collapse
Affiliation(s)
- John C. Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63131, USA; (D.R.); (B.D.K.)
| | | | | |
Collapse
|
|
2
|
van Galen DJM, Meinders Q, Halfwerk FR, Arens J. ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients. ASAIO J 2024; 70:377-386. [PMID: 38324706 PMCID: PMC11057491 DOI: 10.1097/mat.0000000000002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.
Collapse
Affiliation(s)
- Danny J. M. van Galen
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Quint Meinders
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Frank R. Halfwerk
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
- Department of Cardiothoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jutta Arens
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| |
Collapse
|
|
3
|
Ytrebø LM. Risk Factors for Stroke in COVID-19 Patients on Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1098-1100. [PMID: 37439645 DOI: 10.1097/ccm.0000000000005898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Lars Marius Ytrebø
- Department of Anesthesiology, University Hospital of North Norway, Tromsø, Norway
- Anesthesia and Critical Care Research Group, UIT-The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
|
4
|
Grotberg JC, Reynolds D, Kraft BD. Management of severe acute respiratory distress syndrome: a primer. Crit Care 2023; 27:289. [PMID: 37464381 DOI: 10.1186/s13054-023-04572-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
Collapse
Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| |
Collapse
|
|
5
|
Qiu MS, Deng YJ, Yang X, Shao HQ. Cardiac arrest secondary to pulmonary embolism treated with extracorporeal cardiopulmonary resuscitation: Six case reports. World J Clin Cases 2023; 11:4098-4104. [PMID: 37388806 PMCID: PMC10303601 DOI: 10.12998/wjcc.v11.i17.4098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/30/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Massive pulmonary embolism (PE) results in extremely high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide circulatory and oxygenation support and rescue patients with massive PE. However, there are relatively few studies of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiac arrest (CA) secondary to PE. The aim of the present study is to investigate the clinical use of ECPR in conjunction with heparin anticoagulation in patients with CA secondary to PE.
CASE SUMMARY We report the cases of six patients with CA secondary to PE treated with ECPR in the intensive care unit of our hospital between June 2020 and June 2022. All six patients experienced witnessed CA whilst in hospital. They had acute onset of severe respiratory distress, hypoxia, and shock rapidly followed by CA and were immediately given cardiopulmonary resuscitation and adjunctive VA-ECMO therapy. During hospitalization, pulmonary artery computed tomography angiography was performed to confirm the diagnosis of PE. Through anticoagulation management, mechanical ventilation, fluid management, and antibiotic treatment, five patients were successfully weaned from ECMO (83.33%), four patients survived for 30 d after discharge (66.67%), and two patients had good neurological outcomes (33.33%).
CONCLUSION For patients with CA secondary to massive PE, ECPR in conjunction with heparin anticoagulation may improve outcomes.
Collapse
Affiliation(s)
- Min-Shan Qiu
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| | - Yong-Jin Deng
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| | - Xue Yang
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| | - Han-Quan Shao
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| |
Collapse
|
|
6
|
Neumann E, Sahli SD, Kaserer A, Braun J, Spahn MA, Aser R, Spahn DR, Wilhelm MJ. Predictors associated with mortality of veno-venous extracorporeal membrane oxygenation therapy. J Thorac Dis 2023; 15:2389-2401. [PMID: 37324096 PMCID: PMC10267924 DOI: 10.21037/jtd-22-1273] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/10/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND The use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) has rapidly increased in recent years. Today, applications of V-V ECMO include a variety of clinical conditions such as acute respiratory distress syndrome (ARDS), bridge to lung transplantation and primary graft dysfunction after lung transplantation. The purpose of the present study was to investigate in-hospital mortality of adult patients undergoing V-V ECMO therapy and to determine independent predictors associated with mortality. METHODS This retrospective study was conducted at the University Hospital Zurich, a designated ECMO center in Switzerland. Data was analyzed of all adult V-V ECMO cases from 2007 to 2019. RESULTS In total, 221 patients required V-V ECMO support (median age 50 years, 38.9% female). In-hospital mortality was 37.6% and did not statistically vary significantly between indications (P=0.61): 25.0% (1/4) for primary graft dysfunction after lung transplantation, 29.4% (5/17) for bridge to lung transplantation, 36.2% (50/138) for ARDS and 43.5% (27/62) for other pulmonary disease indications. Cubic spline interpolation showed no effect of time on mortality over the study period of 13 years. Multiple logistic regression modelling identified significant predictor variables associated with mortality: age [odds ratio (OR), 1.05; 95% confidence interval (CI): 1.02-1.07; P=0.001], newly detected liver failure (OR, 4.83; 95% CI: 1.27-20.3; P=0.02), red blood cell transfusion (OR, 1.91; 95% CI: 1.39-2.74; P<0.001) and platelet concentrate transfusion (OR, 1.93; 95% CI: 1.28-3.15; P=0.004). CONCLUSIONS In-hospital mortality of patients receiving V-V ECMO therapy remains relatively high. Patients' outcomes have not improved significantly in the observed period. We identified age, newly detected liver failure, red blood cell transfusion and platelet concentrate transfusion as independent predictors associated with in-hospital mortality. Incorporating such mortality predictors into decision making with regards to V-V ECMO use may increase its effectiveness and safety and may translate into better outcomes.
Collapse
Affiliation(s)
- Elena Neumann
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Muriel A. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Raed Aser
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Markus J. Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
|
7
|
Abstract
Mechanical circulatory support (MCS) devices provide temporary or intermediate- to long-term support for acute cardiopulmonary support. In the last 20 to 30 years, tremendous growth in MCS device usage has been seen. These devices offer support for isolated respiratory failure, isolated cardiac failure, or both. Initiation of MCS devices requires the input from multidisciplinary teams using patient factors and institutional resources to guide decision making, along with a planned "exit strategy" for bridge to decision, bridge to transplant, bridge to recovery, or as destination therapy. Important considerations for MCS use include patient selection, cannulation/insertion strategies, and complications of each device.
Collapse
Affiliation(s)
- Suzanne Bennett
- Department of Anesthesiology, University of Cincinnati College of Medicine, 2139 Albert Sabin Way, Cincinnati, OH 45267-0531, USA.
| | - Lauren Sutherland
- Columbia University Irving Medical Center, 622 W 168(th) Street, New York, NY 10032, USA
| | - Promise Ariyo
- Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Frank M O'Connell
- Anesthesiology, Atlanticare Regional Medical Center, 65 W Jimmie Leeds Road, Pomona, NJ 08240, USA
| |
Collapse
|
|
8
|
Crow J, Lindsley J, Cho SM, Wang J, Lantry JH, Kim BS, Tahsili-Fahadan P. Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support. ASAIO J 2022; 68:1419-1427. [PMID: 35593878 PMCID: PMC9675878 DOI: 10.1097/mat.0000000000001758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an increasingly utilized intervention for cardiopulmonary failure. Analgosedation during ECMO support is essential to ensure adequate pain and agitation control and ventilator synchrony, optimize ECMO support, facilitate patient assessment, and minimize adverse events. Although the principles of analgosedation are likely similar for all critically ill patients, ECMO circuitry alters medication pharmacodynamics and pharmacokinetics. The lack of clinical guidelines for analgosedation during ECMO, especially at times of medication shortage, can affect patient management. Here, we review pharmacological considerations, protocols, and special considerations for analgosedation in critically ill adults receiving ECMO support.
Collapse
Affiliation(s)
- Jessica Crow
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - John Lindsley
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jing Wang
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - James H Lantry
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
| | - Bo S. Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pouya Tahsili-Fahadan
- Neurocritical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
- Department of Medical Education, University of Virginia, Inova Fairfax Medical Campus, Falls Church, VA
| |
Collapse
|
|
9
|
Hayes K, Hodgson CL, Webb MJ, Romero L, Holland AE. Rehabilitation of adult patients on extracorporeal membrane oxygenation: A scoping review. Aust Crit Care 2022; 35:575-582. [PMID: 34711492 DOI: 10.1016/j.aucc.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The objective of this study was to conduct a scoping review to comprehensively map the breadth of literature related to the rehabilitation of adult patients whilst on extracorporeal membrane oxygenation (ECMO) and identify gaps and areas for future research. REVIEW METHOD USED This review was conducted using recommended frameworks for methods and reporting including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. DATE SOURCES We searched seven databases from inception to June 2021 and included all study designs and grey literature. REVIEW METHODS Eligibility screening was completed by two independent reviewers according to inclusion and exclusion criteria, with any disagreement resolved by consensus or with consultation with a third reviewer. Two independent reviewers extracted data related to intervention characteristics, patient outcomes, feasibility, safety, hospital outcomes, and mortality using a custom-designed piloted form. RESULTS Of 8507 records, 185 original studies met inclusion criteria, with the majority being small retrospective studies. Rehabilitation was more commonly reported in patients on veno-venous rather than veno-arterial ECMO. Ambulation was the most commonly reported intervention (51% of studies). Critical gaps were identified including incomplete reporting of the intervention along with heterogeneity in the type and timing of outcome measures. Less than 50% of patients met eligibility criteria to participate, but screening for eligibility was infrequently reported (9% of studies). Delivery of rehabilitation during ECMO may be facilitated by an expert multidisciplinary team, along with a strategy that targets low sedation levels and an upper body cannulation approach. CONCLUSIONS Rehabilitation during ECMO is an emerging area of research and mostly consisted of small retrospective single-centre studies. Future research requires more robust methodological designs that include comprehensive screening of potential candidates with reporting of eligibility, more detailed descriptions of the rehabilitation interventions, inclusion of a core outcome set with defined measurement instruments, and consistent timing of outcome measurement.
Collapse
Affiliation(s)
- Kate Hayes
- Department of Physiotherapy, Alfred Health, Victoria, Australia; Discipline of Physiotherapy, La Trobe University, Victoria, Australia.
| | - Carol L Hodgson
- Department of Physiotherapy, Alfred Health, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.
| | - Melissa J Webb
- Department of Physiotherapy, Alfred Health, Victoria, Australia.
| | - Lorena Romero
- Ian Potter Library, Alfred Health, Victoria, Australia.
| | - Anne E Holland
- Department of Physiotherapy, Alfred Health, Victoria, Australia; Monash University, Department of Allergy, Immunology and Respiratory Medicine, Victoria, Australia.
| |
Collapse
|
|
10
|
Saeed O, Tatooles AJ, Farooq M, Schwartz G, Pham DT, Mustafa AK, D'Alessandro D, Abrol S, Jorde UP, Gregoric ID, Radovancevic R, Lima B, Bryner BS, Ravichandran A, Salerno CT, Spencer P, Friedmann P, Silvestry S, Goldstein DJ. Characteristics and outcomes of patients with COVID-19 supported by extracorporeal membrane oxygenation: A retrospective multicenter study. J Thorac Cardiovasc Surg 2022; 163:2107-2116.e6. [PMID: 34112505 PMCID: PMC8130603 DOI: 10.1016/j.jtcvs.2021.04.089] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine characteristics, outcomes, and clinical factors associated with death in patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) support. METHODS A multicenter, retrospective cohort study was conducted. The cohort consisted of adult patients (18 years of age and older) requiring ECMO in the period from March 1, 2020, to September 30, 2020. The primary outcome was in-hospital mortality after ECMO initiation assessed with a time to event analysis at 90 days. Multivariable Cox proportional regression was used to determine factors associated with in-hospital mortality. RESULTS Overall, 292 patients from 17 centers comprised the study cohort. Patients were 49 (interquartile range, 39-57) years old and 81 (28%) were female. At the end of the follow-up period, 19 (6%) patients were still receiving ECMO, 25 (9%) were discontinued from ECMO but remained hospitalized, 135 (46%) were discharged or transferred alive, and 113 (39%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 42% (95% confidence interval [CI], 36%-47%). Factors associated with in-hospital mortality were age (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.06-1.61 per 10 years), renal dysfunction measured according to serum creatinine level (aHR, 1.21; 95% CI, 1.01-1.45), and cardiopulmonary resuscitation before ECMO placement (aHR, 1.87; 95% CI, 1.01-3.46). CONCLUSIONS In patients with severe COVID-19 necessitating ECMO support, in-hospital mortality occurred in fewer than half of the cases. ECMO might serve as a viable modality for terminally ill patients with refractory COVID-19.
Collapse
Affiliation(s)
- Omar Saeed
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Antone J Tatooles
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Ill; Cardiothoracic and Vascular Surgical Associates SC, Advocate Christ Medical Center, Oak Lawn, Ill
| | - Muhammad Farooq
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Gary Schwartz
- Department of Surgery, Baylor University Medical Center, Dallas, Tex
| | - Duc T Pham
- Department of Surgery, Northwestern University, Chicago, Ill
| | - Asif K Mustafa
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Ill; Cardiothoracic and Vascular Surgical Associates SC, Advocate Christ Medical Center, Oak Lawn, Ill
| | | | - Sunil Abrol
- Department of Surgery, New York University Winthrop, New York, NY
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Igor D Gregoric
- Advanced Cardiopulmonary Therapies and Transplantation (Cardiothoracic Surgery), University of Texas Health Science Center, Houston, Tex
| | - Rajko Radovancevic
- Advanced Cardiopulmonary Therapies and Transplantation (Cardiothoracic Surgery), University of Texas Health Science Center, Houston, Tex
| | - Brian Lima
- Department of Cardiothoracic Surgery, North Shore University Hospital, Manhasset, NY
| | | | - Ashwin Ravichandran
- Ascension, Saint Vincent's Medical Center (Cardiothoracic Surgery), Indianapolis, Ind
| | - Christopher T Salerno
- Ascension, Saint Vincent's Medical Center (Cardiothoracic Surgery), Indianapolis, Ind
| | - Philip Spencer
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Patricia Friedmann
- Division of Biostatistics, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Scott Silvestry
- Advent Health Transplant Institute, Division of Cardiothoracic Surgery, Advent Health, Orlando, Fla
| | - Daniel J Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| |
Collapse
|
|
11
|
Ruberto F, Alessandri F, Piazzolla M, Zullino V, Bruno K, Celli P, Diso D, Venuta F, Bilotta F, Pugliese F. Intraoperative use of extracorporeal CO 2 removal (ECCO 2R) and emergency ECMO requirement in patients undergoing lung transplant: a case-matched cohort retrospective study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:22. [PMID: 37386563 DOI: 10.1186/s44158-022-00050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/10/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The use of extracorporeal carbon dioxide removal (ECCO2R) is less invasive than extracorporeal membrane oxygenation (ECMO), and intraoperative control of gas exchange could be feasible. The aim of this study in intermediate intraoperative severity patients undergoing LT was to assess the role of intraoperative ECCO2R on emergency ECMO requirement in patients. METHODS Thirty-eight consecutive patients undergoing lung transplantation (LT) with "intermediate" intraoperative severity in the intervals 2007 to 2010 or 2011 to 2014 were analyzed as historical comparison of case-matched cohort retrospective study. The "intermediate" intraoperative severity was defined as the development of intraoperative severe respiratory acidosis with maintained oxygenation function (i.e., pH <7.25, PaCO2 >60 mmHg, and PaO2/FiO2 >150), not associated with hemodynamic instability. Of these 38 patients, twenty-three patients were treated in the 2007-2010 interval by receiving "standard intraoperative treatment," while 15 patients were treated in the 2011-2014 interval by receiving "standard intraoperative treatment + ECCO2R." RESULTS ECMO requirement was more frequent among patients that received "standard intraoperative treatment" alone than in those treated with "standard intraoperative treatment + ECCO2R" (17/23 vs. 3/15; p = 0.004). The use of ECCO2R improved pH and PaCO2 while mean pulmonary artery pressure (mPAP) decreased. CONCLUSION In intermediate intraoperative severity patients, the use of ECCO2R reduces the ECMO requirement.
Collapse
Affiliation(s)
- Franco Ruberto
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Mario Piazzolla
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Veronica Zullino
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Katia Bruno
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paola Celli
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Diso
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Venuta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Bilotta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Pugliese
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| |
Collapse
|
|
12
|
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19.
Collapse
|
|
13
|
Li Y, Cao C, Huang L, Xiong H, Mao H, Yin Q, Luo X. "Awake" Extracorporeal Membrane Oxygenation Combined With Continuous Renal Replacement Therapy For the Treatment of Severe Chemical Gas Inhalation Lung Injury. J Burn Care Res 2021; 41:908-912. [PMID: 32193543 DOI: 10.1093/jbcr/iraa043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung injury caused by chemical gas inhalation is a common clinically severe disease that very easily progresses to acute respiratory distress syndrome (ARDS). Traditional respiratory support consists mainly of mechanical ventilation, but the prognosis of this condition is still poor. "Awake" extracorporeal membrane oxygenation (ECMO) maintains oxygenation, improves ventilation, adequately allows the injured lungs to rest, and avoids complications associated with sedation, intubation, and mechanical ventilation. Continuous renal replacement therapy (CRRT) can provide better fluid management and reduce pulmonary edema. Herein, we describe the case of a patient with severe chemical gas inhalation lung injury who failed to respond to traditional mechanical ventilation and was subsequently treated with awake ECMO combined with CRRT.
Collapse
Affiliation(s)
- Yang Li
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - ChunShui Cao
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Liang Huang
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - HuaWei Xiong
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - HongTao Mao
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Qin Yin
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - XiaoLong Luo
- Department of Emergency Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| |
Collapse
|
|
14
|
Factors Associated With 30 Day Survival in Adults With Influenza Infection Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2021; 68:732-737. [PMID: 34437328 DOI: 10.1097/mat.0000000000001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) secondary to influenza in adults is associated with a high rate of morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) is a supportive alternative for severe and refractory cases. This study aimed to perform a hospital-based case-control study between February 2018 and February 2020 for determining the factors associated with 30 day survival in adults with severe ARDS caused by influenza infection who are provided ECMO support. A total of 17 adults received ECMO support, mostly veno-venous for hypoxemic respiratory failure, with a 30 day survival rate of 65%. The cohort of patients who did not survive at 30 days compared with the cohort of those who did survive had higher body mass index (34 vs. 31), higher Sequential Organ Failure Assessment score (9.5 vs. 7) and lower Respiratory ECMO Survival Prediction score (2 vs. 4). This study shows the importance of evaluating the severity scores of patients before ECMO support initiation, which offers an acceptable survival in patients with severe ARDS, making it a feasible alternative in critical patients who are refractory to conventional management.
Collapse
|
|
15
|
Procollagen I and III as Prognostic Markers in Patients Treated with Extracorporeal Membrane Oxygenation: A Prospective Observational Study. J Clin Med 2021; 10:jcm10163686. [PMID: 34441982 PMCID: PMC8397027 DOI: 10.3390/jcm10163686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/05/2021] [Accepted: 08/17/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Procollagen peptides have been associated with lung fibroproliferation and poor outcomes in patients with acute respiratory distress syndrome (ARDS). Therefore, serum procollagen concentrations might have prognostic value in ARDS patients treated with extracorporeal membrane oxygenation (ECMO). Methods: In a prospective cohort study, serum N-terminal procollagen I-peptide (PINP) and N-terminal procollagen III-peptide (PIIINP) concentrations in twenty-three consecutive patients with severe ARDS treated with ECMO were measured at the time of ECMO initiation and during the course of treatment. The predictive value of PINP and PIIINP at the time of ECMO initiation was tested with a univariable logistic regression and a receiver operating characteristic (ROC) curve analysis. Results: Thirteen patients survived to intensive care unit (ICU) discharge. Non-survivors had higher serum PINP and PIIINP concentrations at all points in time during the course of treatment. Serum PIIINP at the day of ECMO initiation showed an odds ratio of 1.37 (95% CI 1.10–1.89, p = 0.017) with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.87 (95% CI 0.69–1.00, p = 0.0029) for death during the course of treatment. Conclusions: PINP and PIIINP concentrations differ between survivors and non-survivors in ARDS treated with ECMO. This exploratory hypothesis generating study suggests an association between PIIINP serum concentrations at ECMO initiation and an unfavorable clinical outcome.
Collapse
|
|
16
|
Cumulative Fluid Balance during Extracorporeal Membrane Oxygenation and Mortality in Patients with Acute Respiratory Distress Syndrome. MEMBRANES 2021; 11:membranes11080567. [PMID: 34436331 PMCID: PMC8402131 DOI: 10.3390/membranes11080567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in cases of severe acute respiratory distress syndrome (ARDS) with profound hypoxemia. However, the need for high-volume fluid resuscitation and blood transfusions after ECMO initiation introduces a risk of fluid overload. Positive fluid balance is associated with mortality in critically ill patients, and conservative fluid management for ARDS patients has been shown to shorten both the duration of mechanical ventilation and time spent in intensive care, albeit without a significant effect on survival. Nonetheless, few studies have addressed the influence of fluid balance on clinical outcomes in severe ARDS patients undergoing ECMO. In the current retrospective study, we examined the impact of cumulative fluid balance (CFB) on hospital mortality in 152 cases of severe ARDS treated using ECMO. Overall hospital mortality was 53.3%, and we observed a stepwise positive correlation between CFB and the risk of death. Cox regression models revealed that CFB during the first 3 days of ECMO was independently associated with higher hospital mortality (adjusted hazard ratio 1.110 [95% CI 1.027–1.201]; p = 0.009). Our findings indicate the benefits of a conservative treatment approach to avoid fluid overload during the early phase of ECMO when dealing with severe ARDS patients.
Collapse
|
|
17
|
Kadar RB, Atassi G, Jarzebowski M, Ault ML. Severe Shivering on Venoarterial Extracorporeal Membrane Oxygenation-Raising the Circuit Temperature to Stop Rhabdomyolysis: A Case Report. A A Pract 2021; 14:e01341. [PMID: 33185412 DOI: 10.1213/xaa.0000000000001341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of severe shivering resulting in rhabdomyolysis while on venoarterial extracorporeal membrane oxygenation (ECMO) that resolved after hyperthermia was induced using the ECMO circuit. The patient developed shivering approximately 24 hours after venoarterial ECMO cannulation for refractory ventricular tachycardia. The shivering caused rhabdomyolysis and necessitated cisatracurium infusion. The shivering failed to resolve after the patient was diagnosed and treated for ventilator-associated pneumonia. Suspecting sepsis as the etiology of shivering, the ECMO circuit temperature was increased to 38 °C, and the shivering was resolved. This case demonstrates therapeutic hyperthermia to treat infection-induced severe shivering and rhabdomyolysis while on ECMO.
Collapse
Affiliation(s)
- Rachel B Kadar
- From the Department of Anesthesiology, Section of Critical Care Medicine, Northwestern University, Chicago, Illinois
| | - Giancarlo Atassi
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary Jarzebowski
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.,Department of Anesthesiology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Michael L Ault
- From the Department of Anesthesiology, Section of Critical Care Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
|
18
|
Usagawa Y, Komiya K, Yamasue M, Fushimi K, Hiramatsu K, Kadota JI. Efficacy of extracorporeal membrane oxygenation for acute respiratory failure with interstitial lung disease: a case control nationwide dataset study in Japan. Respir Res 2021; 22:211. [PMID: 34303372 PMCID: PMC8310400 DOI: 10.1186/s12931-021-01805-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Whether acute respiratory failure in patients with interstitial lung disease is reversible remains uncertain. Consequently, indications for extracorporeal membrane oxygenation in these patients are still controversial, except as a bridge to lung transplantation. The objective of this study was to clarify in-hospital mortality and prognostic factors in interstitial lung disease patients undergoing extracorporeal membrane oxygenation. Methods In this case–control study using the Japanese Diagnosis Procedure Combination database, hospitalized interstitial lung disease patients receiving invasive mechanical ventilation and extracorporeal membrane oxygenation from 2010 to 2017 were reviewed. Patients’ characteristics and treatment regimens were compared between survivors and non-survivors to identify prognostic factors. To avoid selection biases, patients treated with extracorporeal membrane oxygenation as a bridge to lung transplantation were excluded. Results A total of 164 interstitial lung disease patients receiving extracorporeal membrane oxygenation were included. Their in-hospital mortality was 74.4% (122/164). Compared with survivors, non-survivors were older and received high-dose cyclophosphamide, protease inhibitors, and antifungal drugs more frequently, but macrolides and anti-influenza drugs less frequently. On multivariate analysis, the following factors were associated with in-hospital mortality: advanced age (odds ratio [OR] 1.043; 95% confidence interval [CI] 1.009–1.078), non-use of macrolides (OR 0.305; 95% CI 0.134–0.698), and use of antifungal drugs (OR 2.416; 95% CI 1.025–5.696). Conclusions Approximately three-quarters of interstitial lung disease patients undergoing extracorporeal membrane oxygenation died in hospital. Moreover, advanced age, non-use of macrolides, and use of antifungal drugs were found to correlate with a poor prognosis.
Collapse
Affiliation(s)
- Yuko Usagawa
- Department of Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Kosaku Komiya
- Department of Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
| | - Mari Yamasue
- Department of Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Kazufumi Hiramatsu
- Department of Medical Safety Management, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun-Ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| |
Collapse
|
|
19
|
Extracorporeal Carbon Dioxide Removal in the Treatment of Status Asthmaticus. Crit Care Med 2021; 48:e1226-e1231. [PMID: 33031151 DOI: 10.1097/ccm.0000000000004645] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Venovenous extracorporeal carbon dioxide removal may be lifesaving in the setting of status asthmaticus. DESIGN Retrospective review. SETTING Medical ICU. PATIENTS Twenty-six adult patients with status asthmaticus treated with venovenous extracorporeal carbon dioxide removal. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic data and characteristics of current and prior asthma treatments were obtained from the electronic medical record. Mechanical ventilator settings, arterial blood gases, vital signs, and use of vasopressors were collected from the closest time prior to cannulation and 24 hours after initiation of extracorporeal carbon dioxide removal. Extracorporeal carbon dioxide removal settings, including blood flow and sweep gas flow, were collected at 24 hours after initiation of extracorporeal carbon dioxide removal. Outcome measures included rates of survival to hospital discharge, ICU and hospital lengths of stay, duration of invasive mechanical ventilation and extracorporeal carbon dioxide removal support, and complications during extracorporeal carbon dioxide removal. Following the initiation of extracorporeal carbon dioxide removal, blood gas values were significantly improved at 24 hours, as were peak airway pressures, intrinsic positive end-expiratory pressure, and use of vasopressors. Survival to hospital discharge was 100%. Twenty patients (76.9%) were successfully extubated while receiving extracorporeal carbon dioxide removal support; none required reintubation. The most common complication was cannula-associated deep venous thrombosis (six patients, 23.1%). Four patients (15.4%) experienced bleeding that required a transfusion of packed RBCs. CONCLUSIONS In the largest series to date, use of venovenous extracorporeal carbon dioxide removal in patients with status asthmaticus can provide a lifesaving means of support until the resolution of the exacerbation, with an acceptably low rate of complications. Early extubation in select patients receiving extracorporeal carbon dioxide removal is safe and feasible and avoids the deleterious effects of positive-pressure mechanical ventilation in this patient population.
Collapse
|
|
20
|
Ruaro B, Salton F, Braga L, Wade B, Confalonieri P, Volpe MC, Baratella E, Maiocchi S, Confalonieri M. The History and Mystery of Alveolar Epithelial Type II Cells: Focus on Their Physiologic and Pathologic Role in Lung. Int J Mol Sci 2021; 22:2566. [PMID: 33806395 PMCID: PMC7961977 DOI: 10.3390/ijms22052566] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/27/2021] [Accepted: 02/28/2021] [Indexed: 12/13/2022] Open
Abstract
Alveolar type II (ATII) cells are a key structure of the distal lung epithelium, where they exert their innate immune response and serve as progenitors of alveolar type I (ATI) cells, contributing to alveolar epithelial repair and regeneration. In the healthy lung, ATII cells coordinate the host defense mechanisms, not only generating a restrictive alveolar epithelial barrier, but also orchestrating host defense mechanisms and secreting surfactant proteins, which are important in lung protection against pathogen exposure. Moreover, surfactant proteins help to maintain homeostasis in the distal lung and reduce surface tension at the pulmonary air-liquid interface, thereby preventing atelectasis and reducing the work of breathing. ATII cells may also contribute to the fibroproliferative reaction by secreting growth factors and proinflammatory molecules after damage. Indeed, various acute and chronic diseases are associated with intensive inflammation. These include oedema, acute respiratory distress syndrome, fibrosis and numerous interstitial lung diseases, and are characterized by hyperplastic ATII cells which are considered an essential part of the epithelialization process and, consequently, wound healing. The aim of this review is that of revising the physiologic and pathologic role ATII cells play in pulmonary diseases, as, despite what has been learnt in the last few decades of research, the origin, phenotypic regulation and crosstalk of these cells still remain, in part, a mystery.
Collapse
Affiliation(s)
- Barbara Ruaro
- Pulmonology Department, University Hospital of Cattinara, 34128 Trieste, Italy; (F.S.); (P.C.); (M.C.)
| | - Francesco Salton
- Pulmonology Department, University Hospital of Cattinara, 34128 Trieste, Italy; (F.S.); (P.C.); (M.C.)
| | - Luca Braga
- ICGEB, Area Science Park, Padriciano, 34128 Trieste, Italy;
| | - Barbara Wade
- City of Health and Science of Turin, Department of Science of Public Health and Pediatrics, University of Torino, 34128 Trieste, Italy;
| | - Paola Confalonieri
- Pulmonology Department, University Hospital of Cattinara, 34128 Trieste, Italy; (F.S.); (P.C.); (M.C.)
| | - Maria Concetta Volpe
- Life Sciences Department, University of Trieste, 34128 Trieste, Italy; (M.C.V.); (S.M.)
| | - Elisa Baratella
- Department of Radiology, Department of Medicine, Surgery and Health Science, University of Trieste, 34128 Trieste, Italy;
| | - Serena Maiocchi
- Life Sciences Department, University of Trieste, 34128 Trieste, Italy; (M.C.V.); (S.M.)
| | - Marco Confalonieri
- Pulmonology Department, University Hospital of Cattinara, 34128 Trieste, Italy; (F.S.); (P.C.); (M.C.)
| |
Collapse
|
|
21
|
Manickavel S. Pathophysiology of respiratory failure and physiology of gas exchange during ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:203-209. [PMID: 33967443 DOI: 10.1007/s12055-020-01042-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 01/11/2023] Open
Abstract
Lungs play a key role in sustaining cellular respiration by regulating the levels of oxygen and carbon dioxide in the blood. This is achieved by exchanging these gases between blood and ambient air across the alveolar capillary membrane by the process of diffusion. In the microstructure of the lung, gas exchange is compartmentalized and happens in millions of microscopic alveolar units. In situations of lung injury, this structural complexity is disrupted resulting in impaired gas exchange. Depending on the severity and the type of lung injury, different aspects of pulmonary physiology are affected. If the respiratory failure is refractory to ventilator support, extracorporeal membrane oxygenation (ECMO) can be utilized to support the gas exchange needs of the body. In ECMO, thin hollow fiber membranes made up of polymethylpentene act as blood-gas interface for diffusion. Decades of innovative engineering with membranes and their alignment with blood and gas flows has enabled modern oxygenators to achieve clinically and physiologically significant amount of gas exchange.
Collapse
Affiliation(s)
- Suresh Manickavel
- Miami Transplant Institute, University of Miami, 1801 NW 9th Ave, Miami, FL 33136 USA
| |
Collapse
|
|
22
|
Semiquantification of Systemic Venous Admixture During Venovenous Extracorporeal Oxygenation Via Bicaval Double-Lumen Cannula in Critically Ill Patients. ASAIO J 2020; 66:23-31. [PMID: 30601181 DOI: 10.1097/mat.0000000000000943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is increasingly utilized in acute reversible cases of severe respiratory failure and as a bridge to lung transplantation. Venovenous extracorporeal membrane oxygenation using a bicaval double-lumen cannula (BCDLC) has several advantages over the traditional ECMO configuration; however, it also presents with several unique challenges. The assessment and quantification of venous admixture is difficult due to the specific position of BCDLC within the circulatory system. We describe the nature of the double-lumen bicaval venovenous ECMO cannula and relevant specific issues associated with monitoring complex details of oxygenation within different parts of circulation, including existing barriers for quantification of recirculation and venous admix. New conceptual approach to the quantification of venous admix is described. Right side echocardiographic contrast, when sequentially injected in separate superior vena cava (SVC) and inferior vena cava (IVC) venous basins, bypasses drainage ports of the catheter in double-lumen bicaval VV-ECMO configuration together with deoxygenated returning from the periphery venous blood. It was easily detectable entering right heart chambers by two- and three-dimensional echocardiography. Amount of bubbles from the agitated fluid contrast within right atrium indicates relative amount of venous admixture in relation to the returning from the oxygenator blood which is bubble free.
Collapse
|
|
23
|
How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation. Chest 2020; 158:1036-1045. [DOI: 10.1016/j.chest.2020.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/30/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023] Open
|
|
24
|
Abstract
Sepsis is being recognized as an important complication of extracorporeal membrane oxygenation (ECMO) and its presence is a poor prognostic marker and increases the overall mortality. The survival rate differs in the various types of cannulation techniques. Adult patients with prolonged duration of ECMO constitute the major risk population. Ventilator-associated pneumonia and bloodstream infections form the main sources of sepsis in these patients. It is important to know the most common etiological agents for sepsis in ECMO, which varies partly with the local epidemiology of the hospitals. A high index of suspicion, drawing adequate volumes for blood culture and early and timely administration of appropriate empirical antimicrobials can substantially decrease the morbidity and mortality in this high-risk population. The dosing of antimicrobials is influenced by the pharmacological variations on ECMO machine and is an important consideration. Infection control practices are of paramount importance and need to be followed meticulously to prevent sepsis in ECMO.
Collapse
|
|
25
|
Should Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to the Lowest Tolerable Settings? No. Crit Care Med 2020; 47:1147-1149. [PMID: 31162204 DOI: 10.1097/ccm.0000000000003865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
|
26
|
Zhang R, Xu Y, Sang L, Chen S, Huang Y, Nong L, Yang C, Liu X, Liu D, Xi Y, He W, Wei B, He J, Li Y, Liu X. Factors associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation. Respir Res 2020; 21:85. [PMID: 32293451 PMCID: PMC7160893 DOI: 10.1186/s12931-020-01355-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative Extracorporeal membrane oxygenation (ECMO) is increasingly being applied as life-support for lung transplantation patients. However, factors associated with this procedure in lung transplantation patients have not yet been characterized. The aim of this study was to identify preoperative factors of intraoperative ECMO support during lung transplantation and to evaluated the outcome of lung transplantation patients supported with ECMO. METHODS Patients underwent lung transplantation treated with and without ECMO in Guangzhou Institute of Respiratory Diseases between January 2015 to August 2018 were retrospectively reviewed. Patient demographics and clinical variables were collected and analyzed. Multivariate logistic regression was performed to identify factors independently associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation. RESULTS During the study period, 138 patients underwent lung transplantation at our institution, the mean LAS was (56.63 ± 18.39) (range, 32.79 to 88.70). Fourty four patients were treated with veno-venous/veno-arterial ECMO. Among the patients, 32 patients wean successfully ECMO after operation, 12 patients remain ECMO after operation, and 32 patients (62.74%) survived to hospital discharge. In multiple analysis, the following factors were associated with intraoperative ECMO support: advanced age, high PAP before operation, duration of mechanical ventilation before operation, a higher APACHE II and primary diagnosis for transplantation. The overall survival rates at 1, 3, and 12 months were 90.91, 72.73, and 56.81% in the ECMO group, and 95.40, 82.76, and 73.56% in the non-ECMO group, respectively (log-rank P = 0.081). Patients who underwent single lung transplant had a lower survival rates in ECMO group as compared with non-ECMO group at 1, 3, and 12 months (90.47% vs 98.25, 71.43% vs 84.21, and 52.38% vs 75.44%) (log-rank P = 0.048). CONCLUSIONS The preoperative factors of intraoperative ECMO support during lung transplantation included age, high PAP before operation, preoperative mechanical ventilation, a higher APACHE II and primary diagnosis for transplantation based on multivariate analysis.
Collapse
Affiliation(s)
- Rong Zhang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yonghao Xu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Ling Sang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Sibei Chen
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yongbo Huang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Lingbo Nong
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Chun Yang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Xuesong Liu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Dongdong Liu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yin Xi
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Weiqun He
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Bing Wei
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Jianxing He
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yimin Li
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Xiaoqing Liu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China.
| |
Collapse
|
|
27
|
Schmidt M, Pham T, Arcadipane A, Agerstrand C, Ohshimo S, Pellegrino V, Vuylsteke A, Guervilly C, McGuinness S, Pierard S, Breeding J, Stewart C, Ching SSW, Camuso JM, Stephens RS, King B, Herr D, Schultz MJ, Neuville M, Zogheib E, Mira JP, Rozé H, Pierrot M, Tobin A, Hodgson C, Chevret S, Brodie D, Combes A. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med 2020; 200:1002-1012. [PMID: 31144997 DOI: 10.1164/rccm.201806-1094oc] [Citation(s) in RCA: 192] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.Objectives: To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.Methods: This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs.Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO PaO2/FiO2 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm H2O), driving pressure (20 ± 7 vs. 14 ± 4 cm H2O), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.Conclusions: Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.
Collapse
Affiliation(s)
- Matthieu Schmidt
- INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, UPMC Univ Paris 06, Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris, Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e terapie ad alta specializzazione, Palermo, Italy
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | | | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Christophe Guervilly
- Center for Studies and Research on Health Services and Quality of Life EA3279, Service de Medecine Intensive et Reanimation, CHU Hopital Nord, Assistance Publique Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Shay McGuinness
- Cardiothoracic & Vascular ICU, Auckland City Hospital, Auckland, New Zealand
| | - Sophie Pierard
- Pôle de Recherche Cardiovasculaire, Institute de Recherche Expérimentale et Clinique, Cardiothoracic Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jeff Breeding
- St. Vincent's Hospital, New South Wales, Sydney, Australia
| | - Claire Stewart
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney University Medical School, Sydney, New South Wales, Australia
| | - Simon Sin Wai Ching
- Department of Adult Intensive Care, Queen Mary Hospital, the University of Hong Kong, Hong Kong
| | - Janice M Camuso
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Bobby King
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | | | | | - Mathilde Neuville
- Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, AP-HP, Paris, France.,UMR1148, LVTS, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
| | - Elie Zogheib
- Cardiothoracic and Vascular Intensive Care Unit, Amiens University Hospital, Amiens, France.,INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - Jean-Paul Mira
- Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Universitaire de Paris Centre, Médecine Intensive RéanimationHôpital Cochin, Paris, France.,Paris Descartes Sorbonne Paris Cité University, Paris, France.,Department of Infection, Immunity and Inflammation, Cochin Institute, Inserm U1016, Paris, France
| | - Hadrien Rozé
- South Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Pessac, France
| | - Marc Pierrot
- Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Anthony Tobin
- Department of Critical Care Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Carol Hodgson
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Sylvie Chevret
- Biostatistics Team, Saint-Louis Hospital, AP-HP, Paris, France; and.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Alain Combes
- INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, UPMC Univ Paris 06, Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris, Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| |
Collapse
|
|
28
|
Venovenous extra-corporeal membrane oxygenation for severe acute respiratory distress syndrome: a matched cohort study. Chin Med J (Engl) 2020; 132:2192-2198. [PMID: 31503052 PMCID: PMC6797139 DOI: 10.1097/cm9.0000000000000424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although the use of extra-corporeal membrane oxygenation (ECMO) has been rapidly increasing, the benefit of ECMO in patients with acute respiratory distress syndrome (ARDS) remains unclear. Our objective was to investigate the effect of venovenous ECMO (VV-ECMO) on adult patients with severe ARDS. METHODS We conducted a multi-center, retrospective, cohort study in the intensive care units (ICUs) of six teaching hospitals between January 2013 and December 2018. Patients with severe ARDS who received VV-ECMO support were included. The detailed demographic data and physiologic data were used to match ARDS patients without ECMO. The primary endpoint was the 28-day mortality. RESULTS Ninety-nine patients with severe ARDS supported by VV-ECMO and 72 patients without ECMO were included in this study. The acute physiology and chronic health evaluation II score was 23.1 ± 6.3 in the ECMO group and 24.8 ± 8.5 in the control group (P = 0.1195). The sequential organ failure assessment score was 12.8 ± 3.4 in the ECMO group and 13.7 ± 3.5 in the control group (P = 0.0848). The 28-day mortality of patients with ECMO support was 39.4%, and that of the control group was 55.6%. The survival analysis curve showed that the 28-day mortality in the ECMO group was significantly lower than that in the control group (P = 0.0097). Multivariate Cox regression analysis showed that the independent predictors of the 28-day mortality were the requirement of vasopressors before ECMO (hazard ratio [HR]: 1.006; 95% confidence interval [CI]: 1.001-1.013; P = 0.030) and duration of mechanical ventilation before ECMO (HR: 3.299; 95% CI: 1.264-8.609; P = 0.034). CONCLUSIONS This study showed that ECMO improved the survival of patients with severe ARDS. The duration of mechanical ventilation and the requirement of vasopressors before ECMO might be associated with an increased risk of death.
Collapse
|
|
29
|
Martucci G, Grasselli G, Tanaka K, Tuzzolino F, Panarello G, Schmidt M, Bellani G, Arcadipane A. Hemoglobin trigger and approach to red blood cell transfusions during veno-venous extracorporeal membrane oxygenation: the international TRAIN-ECMO survey. Perfusion 2020; 34:39-48. [PMID: 30966906 DOI: 10.1177/0267659119830526] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Optimal red blood cell transfusion practice during veno-venous extracorporeal membrane oxygenation (VV ECMO) is still under debate. This survey aimed to assess the Hb trigger (also comparing with other critically ill patients) and major physiologic determinants considered for transfusions during veno-venous extracorporeal membrane oxygenation. METHODS Voluntary Web-based survey, endorsed by the European Society of Intensive Care Medicine, conducted among VV ECMO pratictioners worldwide. RESULTS A total of 447 respondents worldwide answered the questionnaire: 277 (61.9%) from Europe, 99 (22.1%) from North America, 36 (8.2%) from Asia and Oceania, and 35 (7.8%) from Central and South America. Among the respondents, 59.2% managed less than 12 venous extracorporeal membrane oxygenation runs/year, 19.4% between 12 and 24 runs/year, and 21.4% more than 24 runs/year. Of the respondents, 54.4% do not use a predefined Hb trigger in veno-venous extracorporeal membrane oxygenation, and, while the rate of adoption of a defined trigger varied worldwide, the effective value of Hb did not differ significantly among macro-regions. In patients on veno-venous extracorporeal membrane oxygenation, the Hb trigger to initiate red blood cell transfusion, was higher than in other critically ill patients: 9.1 ± 1.8 g/dL versus 8.3 ± 1.7 g/dL, p < 0.01. The Hb trigger was lower in centers with more than 24 venous extracorporeal membrane oxygenation runs/year (8.4 mg/dL (95% CI: 7.7-8.9)); (8.9 mg/dL (95% CI: 8.2-9.7)) in centers with between 12 and 24 venous extracorporeal membrane oxygenation runs/year; and (9.6 mg/dL (95% CI: 9.1-10.0)) in centers with fewer than 12 venous extracorporeal membrane oxygenation runs/year (p < 0.01). Several and variable adjunctive parameters are considered in cases of uncertainty for transfusion: the principal are hemodynamic status, SvO2, lactates, and fluid balance. CONCLUSION Although the use of a predefined Hb trigger is still under-adopted among centers with low or median extracorporeal membrane oxygenation case volume, the majority of respondents use a higher Hb trigger for veno-venous extracorporeal membrane oxygenation patients compared with other critically ill patients. Higher volume centers tolerate lower Hb levels.
Collapse
Affiliation(s)
- Gennaro Martucci
- 1 Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Giacomo Grasselli
- 2 Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy.,3 Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Kenichi Tanaka
- 4 Department of Anesthesiology, University of Maryland, Baltimore, MD, USA
| | - Fabio Tuzzolino
- 5 Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Giovanna Panarello
- 1 Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Matthieu Schmidt
- 6 Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,7 Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Giacomo Bellani
- 8 Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,9 Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Antonio Arcadipane
- 1 Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| |
Collapse
|
|
30
|
Lee YY, Baik HJ, Lee H, Kim CH, Chung RK, Han JI, Joo H, Woo JH. Heparin-free veno-venous extracorporeal membrane oxygenation in a multiple trauma patient: A case report. Medicine (Baltimore) 2020; 99:e19070. [PMID: 32000456 PMCID: PMC7004685 DOI: 10.1097/md.0000000000019070] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) in multiple trauma patients with post-traumatic respiratory failure can be quite challenging because of the need for systemic anticoagulation, which may lead to excessive bleeding. In the last decade, there is a growing body of evidence that veno-venous ECMO (VV-ECMO) is lifesaving in multiple trauma patients with acute respiratory distress syndrome, thanks to technical improvements in ECMO devices. PATIENT CONCERNS We report a case of a 17-year-old multiple trauma patient who was drunken and had confused mentality. DIAGNOSES She was suffered from critical respiratory failure (life-threatening hypoxemia and severe hypercapnia/acidosis lasting for 70 minutes) accompanied by cardiac arrest and trauma-induced coagulopathy during general anesthesia. INTERVENTIONS We decided to start heparin-free VV-ECMO after cardiac arrest considering risk of hemorrhage. OUTCOMES She survived with no neurologic sequelae after immediate treatment with heparin-free VV-ECMO. LESSONS Heparin-free VV-ECMO can be used as a resuscitative therapy in multiple trauma patients with critical respiratory failure accompanied by coagulopathy. Even in cases in which life-threatening hypoxemia and severe hypercapnia/acidosis last for >1 hours during CPR for cardiac arrest, VV-ECMO could be considered a potential lifesaving treatment.
Collapse
Affiliation(s)
- Youn Young Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Hospital
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Heeseung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Chi Hyo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Rack Kyung Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Jong In Han
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hyunyoung Joo
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Hospital
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| |
Collapse
|
|
31
|
Galiè N, Palazzini M, Manes A. Extracorporeal cardiopulmonary support in acute high-risk pulmonary embolism: still waiting for solid evidence. Eur Heart J 2019; 39:4205-4207. [PMID: 30239710 DOI: 10.1093/eurheartj/ehy507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Massimiliano Palazzini
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Alessandra Manes
- Cardiovascular and Thoracic Department, Bologna University Hospital, Bologna, Italy
| |
Collapse
|
|
32
|
Dzierba AL, Abrams D, Madahar P, Muir J, Agerstrand C, Brodie D. Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation. J Crit Care 2019; 53:98-106. [DOI: 10.1016/j.jcrc.2019.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/09/2019] [Accepted: 05/27/2019] [Indexed: 11/15/2022]
|
|
33
|
Saemann L, Schmucker C, Rösner L, Beyersdorf F, Benk C. Perfusion parameters and target values during extracorporeal cardiopulmonary resuscitation: a scoping review protocol. BMJ Open 2019; 9:e030562. [PMID: 31473622 PMCID: PMC6720332 DOI: 10.1136/bmjopen-2019-030562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/09/2019] [Accepted: 08/13/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly applied in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients. Treatment results are promising, but the efficacy and safety of the procedure are still unclear. Currently, there are no recommended target perfusion parameters during eCPR, the lack of which could result in inadequate (re)perfusion. We aim to perform a scoping review to explore the current literature addressing target perfusion parameters, target values, corresponding survival rates and neurologic outcomes in OHCA and IHCA patients treated with eCPR. METHODS AND ANALYSIS To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library. We will also check references of relevant articles and perform a cited reference research (forward citation tracking).Two independent reviewers will screen titles and abstracts, check full texts for eligibility and perform data extraction. We will resolve dissent by consensus, moderated by a third reviewer. We will include observational and controlled studies addressing target perfusion parameters and outcomes such as survival rates and neurologic findings in OHCA and IHCA patients treated with eCPR. Data extraction tables will be set up, including study and patients' characteristics, aim of study, details on eCPR including target perfusion parameters and reported outcomes. We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe potential clusters and/or gaps. ETHICS AND DISSEMINATION An ethical approval is not needed. We intend to publish the scoping review in a peer-reviewed journal and present results on a scientific meeting.
Collapse
Affiliation(s)
- Lars Saemann
- Department of Cardiovascular Surgery, University Hospital Freiburg Cardiac Centre Freiburg Bad Krozingen Freiburg Branch, Freiburg, Germany
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Freiburg, Germany
| | - Lisa Rösner
- Department of Cardiovascular Surgery, University Hospital Freiburg Cardiac Centre Freiburg Bad Krozingen Freiburg Branch, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg Cardiac Centre Freiburg Bad Krozingen Freiburg Branch, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Hospital Freiburg Cardiac Centre Freiburg Bad Krozingen Freiburg Branch, Freiburg, Germany
| |
Collapse
|
|
34
|
Nam KH, Koh Y, Lim CM, Huh JW, Jung SH, Kang PJ, Lim JY, Hong SB. Central Extracorporeal Membrane Oxygenation for Bridging of Right-Sided Heart Failure to Lung Transplantation: A Single-Center Experience and Literature Review. J Cardiothorac Vasc Anesth 2019; 33:1873-1876. [DOI: 10.1053/j.jvca.2019.01.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/23/2019] [Accepted: 01/25/2019] [Indexed: 01/30/2023]
|
|
35
|
Macielak S, Burcham P, Whitson B, Abdel-Rasoul M, Rozycki A. Impact of anticoagulation strategy and agents on extracorporeal membrane oxygenation therapy. Perfusion 2019; 34:671-678. [DOI: 10.1177/0267659119842809] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Extracorporeal membrane oxygenation mandates balancing the risk of thromboembolic complications with bleeding. We aimed to evaluate pragmatic anticoagulation regimens during extracorporeal membrane oxygenation and compare thromboembolic and bleeding outcomes. Methods: This retrospective, single-center study reviewed patients on venovenous or venoarterial extracorporeal membrane oxygenation for a minimum of 24 hours over a 5-year period. The primary outcome was composite thromboembolic events per day of extracorporeal membrane oxygenation. Secondary outcomes included composite bleeding complications, percent of measured activated partial thromboplastin times in goal range, and comparing events with therapeutic anticoagulation for the majority of the extracorporeal membrane oxygenation run (>50% of time on extracorporeal membrane oxygenation) versus non-therapeutic anticoagulation (therapeutic anticoagulation <50% of time). Results: For the primary analysis, 100 patients received heparin, 10 received bivalirudin, and 43 were transitioned between heparin and bivalirudin. No significant differences were identified comparing the heparin group to the bivalirudin (RR = 0.427, p = 0.156) or transitioned group (RR = 1.274, p = 0.325). There were no differences in the rate of bleeding events when comparing the heparin group to the bivalirudin (RR = 0.626, p = 0.250) or transitioned group (RR = 0.742, p = 0.116). An increased number of adjustments to the anticoagulants was associated with a statistically higher rate of bleeding events per day (p = 0.006). Conclusion: There were no differences in thromboembolic or bleeding events when comparing different anticoagulant regimens. Adjustments to the anticoagulants are more likely to occur when bleeding is observed. Due to variability in anticoagulation, there is a need to standardize anticoagulation with extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- Shea Macielak
- Department of Pharmacy, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Pamela Burcham
- Department of Pharmacy, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Bryan Whitson
- Department of Cardiothoracic Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Mahmoud Abdel-Rasoul
- Department of Biomedical Informatics, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Alan Rozycki
- Department of Pharmacy, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
|
36
|
DeMartino ES, Braus NA, Sulmasy DP, Bohman JK, Stulak JM, Guru PK, Fuechtmann KR, Singh N, Schears GJ, Mueller PS. Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations. Mayo Clin Proc 2019; 94:620-627. [PMID: 30853261 PMCID: PMC10893957 DOI: 10.1016/j.mayocp.2018.09.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/20/2018] [Accepted: 09/24/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology. PATIENTS AND METHODS We retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation. RESULTS Of 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death. CONCLUSION For most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.
Collapse
Affiliation(s)
- Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN.
| | - Nicholas A Braus
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
| | - Daniel P Sulmasy
- Department of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - J Kyle Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | - Gregory J Schears
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Paul S Mueller
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
|
37
|
|
|
38
|
Burgueño P, González C, Sarralde A, Gordo F. Transporte interhospitalario con membrana de oxigenación extracorpórea: cuestiones a resolver. Med Intensiva 2019; 43:90-102. [DOI: 10.1016/j.medin.2018.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 01/07/2018] [Accepted: 01/19/2018] [Indexed: 12/22/2022]
|
|
39
|
Zhang XP, Zhang WT, Qiu Y, Ju MJ, Tu GW, Luo Z. Understanding Gene Therapy in Acute Respiratory Distress Syndrome. Curr Gene Ther 2019; 19:93-99. [PMID: 31267871 DOI: 10.2174/1566523219666190702154817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023]
Abstract
Acute Respiratory Distress Syndrome (ARDS) and its complications remain lifethreatening conditions for critically ill patients. The present therapeutic strategies such as prone positioning ventilation strategies, nitric oxide inhalation, restrictive intravenous fluid management, and extracorporeal membrane oxygenation (ECMO) do not contribute much to improving the mortality of ARDS. The advanced understanding of the pathophysiology of acute respiratory distress syndrome suggests that gene-based therapy may be an innovative method for this disease. Many scientists have made beneficial attempts to regulate the immune response genes of ARDS, maintain the normal functions of alveolar epithelial cells and endothelial cells, and inhibit the fibrosis and proliferation of ARDS. Limitations to effective pulmonary gene therapy still exist, including the security of viral vectors and the pulmonary defense mechanisms against inhaled particles. Here, we summarize and review the mechanism of gene therapy for acute respiratory distress syndrome and its application.
Collapse
Affiliation(s)
- Xue-Peng Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Wei-Tao Zhang
- Department of Urology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- Shanghai Key Laboratory of Organ Transplantation, No. 179 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Yue Qiu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Min-Jie Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, No. 668 Jinghu Road, Huli District, Xiamen 361015, China
| |
Collapse
|
|
40
|
Tipograf Y, Liou P, Oommen R, Agerstrand C, Abrams D, Brodie D, Bacchetta M. A decade of interfacility extracorporeal membrane oxygenation transport. J Thorac Cardiovasc Surg 2018; 157:1696-1706. [PMID: 30655061 DOI: 10.1016/j.jtcvs.2018.09.139] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/17/2018] [Accepted: 09/22/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) is used to provide support for patients with cardiopulmonary failure. Best available medical management often fails in these patients and referring hospitals have no further recourse for escalating care apart from transfer to a tertiary facility. In severely unstable patients, the only option might be to use ECMO to facilitate safe transport. This study aimed to examine the characteristics and outcomes of patients transported while receiving ECMO. METHODS Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients transported while receiving ECMO to Columbia University Medical Center between January 1, 2008, and December 31, 2017. RESULTS Two hundred sixty five adult patients were safely transported while receiving ECMO with no transport-related complications that adversely affected outcomes. Transport distance ranged from 0.2 to 7084 miles with a median distance of 16.9 miles. One hundred eighty-three (69%) received on veno-venous, 72 (27%) veno-arterial, and 10 (3.8%) veno-venous arterial or veno-arterial venous configurations. Two hundred ten (79%) cannulations were performed at our institution at the referring hospital. Sixty-four percent of patients transported while receiving ECMO survived to hospital discharge. CONCLUSIONS Interfacility transport during ECMO was shown to be safe and effective with minimal complications and favorable outcomes when performed at an experienced referral center using stringently applied protocols.
Collapse
Affiliation(s)
- Yuliya Tipograf
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Peter Liou
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Roy Oommen
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
| |
Collapse
|
|
41
|
Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Med 2018; 46:1820-1831. [PMID: 30247273 PMCID: PMC6277052 DOI: 10.1097/ccm.0000000000003406] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. DATA SOURCES We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. STUDY SELECTION AND DATA EXTRACTION Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. DATA SYNTHESIS Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. CONCLUSIONS Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.
Collapse
Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Carolyn S. Calfee
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| |
Collapse
|
|
42
|
When the momentum has gone: what will be the role of extracorporeal lung support in the future? Curr Opin Crit Care 2018; 24:23-28. [PMID: 29140963 DOI: 10.1097/mcc.0000000000000475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW There has been expanding interest in and use of extracorporeal support in respiratory failure concurrent with technological advances and predominantly observational data demonstrating improved outcomes. However, until there is more available data from rigorous, high-quality randomized studies, the future of extracorporeal support remains uncertain. RECENT FINDINGS Outcomes for patients supported with extracorporeal devices continue to show favorable trends. There are several large randomized controlled trials that are in various stages of planning or completion for extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) in the acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD), which may help clarify the role of this technology for these disease processes, and which stand to have a significant impact on a large proportion of patients with acute respiratory failure. Novel applications of extracorporeal lung support include optimization of donor organ quality through ex-vivo perfusion and extracorporeal cross-circulation, allowing for multimodal therapeutic interventions. SUMMARY Despite the ongoing rise in ECMO use for acute respiratory failure, its true value will not be known until more information is gleaned from prospective randomized controlled trials. Additionally, there are modalities beyond the current considerations for extracorporeal support that have the potential to revolutionize respiratory failure, particularly in the realm of chronic lung disease and lung transplantation.
Collapse
|
|
43
|
Allyn J, Ferdynus C, Lo Pinto H, Bouchet B, Persichini R, Vandroux D, Puech B, Allou N. Complication patterns in patients undergoing venoarterial extracorporeal membrane oxygenation in intensive care unit: Multiple correspondence analysis and hierarchical ascendant classification. PLoS One 2018; 13:e0203643. [PMID: 30204777 PMCID: PMC6133279 DOI: 10.1371/journal.pone.0203643] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/26/2018] [Indexed: 11/18/2022] Open
Abstract
Background Treatment by venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used today, even though it is associated with high risks of complications and death. While studies have focused on the relationship between some of these complications and the risk of death, the relationship between different complications has never been specifically examined, despite the fact that the occurrence of one complication is known to favor the occurrence of others. Our objective was to describe the relationship between complications in patients undergoing VA-ECMO in intensive care unit (ICU) and to identify, if possible, patterns of patients according to complications. Methods and findings As part of a retrospective cohort study, we conducted a multiple correspondence analysis followed by a hierarchical ascendant classification in order to identify patterns of patients according to main complications (sepsis, thromboembolic event, major transfusion, major bleeding, renal replacement therapy) and in-ICU death. Our cohort of 145 patients presented an in-ICU mortality rate of 50.3%. Morbidity was high, with 36.5% of patients presenting three or more of the five complications studied. Multiple correspondence analysis revealed a cumulative inertia of 76.9% for the first three dimensions. Complications were clustered together and clustered close to death, prompting the identification of four patterns of patients according to complications, including one with no complications. Conclusions Our study, based on a large cohort of patients undergoing VA-ECMO in ICU and presenting a mortality rate comparable to that reported in the literature, identified numerous and often interrelated complications. Multiple correspondence analysis and hierarchical ascendant classification yielded clusters of patients and highlighted specific links between some of the complications studied. Further research should be conducted in this area.
Collapse
Affiliation(s)
- Jérôme Allyn
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
- Departement d’Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
- * E-mail:
| | - Cyril Ferdynus
- Unité de Soutien Méthodologique, Centre Hospitalier Universitaire de La Réunion, Saint-Denis, France
- INSERM, CIC 1410, Saint-Pierre, France
| | - Hugo Lo Pinto
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Bruno Bouchet
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Romain Persichini
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - David Vandroux
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Berenice Puech
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Nicolas Allou
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
- Departement d’Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| |
Collapse
|
|
44
|
Meneveau N, Guillon B, Planquette B, Piton G, Kimmoun A, Gaide-Chevronnay L, Aissaoui N, Neuschwander A, Zogheib E, Dupont H, Pili-Floury S, Ecarnot F, Schiele F, Deye N, de Prost N, Favory R, Girard P, Cristinar M, Ferré A, Meyer G, Capellier G, Sanchez O. Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases. Eur Heart J 2018; 39:4196-4204. [DOI: 10.1093/eurheartj/ehy464] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/13/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Boulevard Fleming, Besançon, France
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
| | - Benoit Guillon
- Department of Cardiology, University Hospital Jean Minjoz, Boulevard Fleming, Besançon, France
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou and Université Paris Descartes, 20 rue Leblanc, Paris, France
| | - Gaël Piton
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
- Medical Intensive Care Unit, University Hospital Jean Minjoz, Boulevard Fleming, Besancon, France
| | - Antoine Kimmoun
- Service de Médecine Intensive et Réanimation Brabois, Institut Lorrain du Coeur et des Vaisseaux, CHRU de Nancy, Rue du Morvan, Vandoeuvre les Nancy, France
- U1116, Faculté de Médecine de Nancy, 9 Avenue de la Forêt de Haye, Vandoeuvre les Nancy, France
| | - Lucie Gaide-Chevronnay
- Pôle Anesthésie Réanimation, Hôpital Michallon, CHU Grenoble Alpes, Avenue Maquis du Grésivaudan, La Tronche, France
| | - Nadia Aissaoui
- Department of Critical Care Unit, Hôpital Européen-Georges-Pompidou (HEGP), Assistance Publique-hôpitaux de Paris (AP-HP), 20 rue Leblanc, Paris, France
- Université Paris-Descartes, Inserm U970, 56 rue Leblanc, Paris, France
| | - Arthur Neuschwander
- Surgical Intensive Care Unit, Hôpital Européen-Georges-Pompidou (HEGP), Assistance Publique-hôpitaux de Paris (AP-HP), 20 rue Leblanc, Paris, France
| | - Elie Zogheib
- Cardiothoracic Intensive Care Department, Amiens University Hospital, Amiens, France
- INSERM U1088, Jules Verne University of Picardy, Chemin du Thil, Amiens, France
| | - Hervé Dupont
- Cardiothoracic Intensive Care Department, Amiens University Hospital, Amiens, France
- INSERM U1088, Jules Verne University of Picardy, Chemin du Thil, Amiens, France
| | - Sebastien Pili-Floury
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
- Surgical Intensive Care Unit and Department of Anesthesiology, University Hospital Jean Minjoz, Boulevard Fleming, Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Jean Minjoz, Boulevard Fleming, Besançon, France
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, Boulevard Fleming, Besançon, France
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
| | - Nicolas Deye
- Service de Réanimation médicale et toxicologique, Hôpital Lariboisière, Assistance Publique-hôpitaux de Paris (AP-HP), 2 rue Ambroise Paré, Paris Cedex 10, France
- Inserm UMR-S 942, Hôpital Lariboisière, 41 Boulevard de la Chapelle, Paris Cedex 10, France
| | - Nicolas de Prost
- Service de Réanimation médicale, Hôpital Henri Mondor, Assistance Publique-hôpitaux de Paris (AP-HP), 51 avenue du Maréchal de Lattre de Tassigny, Créteil Cedex, France
| | - Raphaël Favory
- Centre de Réanimation, CHU de Lille—Hôpital Salengro, Rue Emile Laine, Lille Cedex, France
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, L’Institut Mutualiste Montsouris, 42 boulevard Jourdan, Paris, France
| | - Mircea Cristinar
- Hôpitaux Universitaires de Strasbourg, 1 Quai Louis Pasteur, Strasbourg, France
| | - Alexis Ferré
- Service de réanimation médicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique—Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, Paris, France
| | - Guy Meyer
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou and Université Paris Descartes, 20 rue Leblanc, Paris, France
| | - Gilles Capellier
- EA3920, University of Burgundy Franche-Comté, 19 rue Ambroise Paré, Besançon, France
- Medical Intensive Care Unit, University Hospital Jean Minjoz, Boulevard Fleming, Besancon, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou and Université Paris Descartes, 20 rue Leblanc, Paris, France
| |
Collapse
|
|
45
|
Perioperative Extracorporeal Cardiopulmonary Resuscitation: The Defibrillator of the 21st Century?: A Case Report. A A Pract 2018; 11:87-89. [PMID: 29634540 DOI: 10.1213/xaa.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Veno-arterial-extracorporeal membrane oxygenation (ECMO) for cardiopulmonary resuscitation (ECMO-CPR) has been recommended by new resuscitation guidelines in the United Kingdom. Our recently established yet unfunded ECMO-CPR service has thus far treated 6 patients, with 3 making a good recovery. One patient suffered a catastrophic perioperative complication through glycine absorption and we are in no doubt that she would not have survived without ECMO. We argue for a pragmatic approach to funding of ECMO-CPR because observational evidence suggests superiority over traditional resuscitation and there exists major methodological and ethical barriers to randomized controlled studies. We also call for high-quality observational evidence in the perioperative setting.
Collapse
|
|
46
|
Acute skeletal muscle wasting and relation to physical function in patients requiring extracorporeal membrane oxygenation (ECMO). J Crit Care 2018; 48:1-8. [PMID: 30118978 DOI: 10.1016/j.jcrc.2018.08.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/04/2018] [Accepted: 08/04/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Muscle weakness is common in patients requiring extracorporeal membrane oxygenation (ECMO), but early identification is challenging. This study aimed to 1) quantify the change in quadriceps size and quality (echogenicity) from baseline to day 10 using ultrasound in patients requiring ECMO, 2) determine the relationship between ultrasound measures, muscle strength and highest mobility level. MATERIALS AND METHODS Prospective cohort study involving ultrasound measurement of quadriceps at baseline, days 10 and 20. Muscle strength and highest mobility level were assessed at days 10 and 20 using the Medical Research Council sum-score (MRC), hand-held dynamometry (HHD) and the ICU mobility scale (IMS). RESULTS 25 patients (age 49 ± 14 years, 44% male) received ECMO. There was a significant reduction (-19%, p < .001) in rectus femoris cross-sectional area by day 10. Echogenicity did not change over time. There was a negative correlation between echogenicity and MRC at day 10 (r = -0.66) and HHD at day 20 (r = -0.81). At day 20, there was a moderate correlation between total muscle thickness and IMS (rho = 0.59) and MRC (rho = 0.56). CONCLUSIONS In patients requiring ECMO there was marked wasting of the quadriceps over the first 10 days. Ultrasound measures were related to muscle strength and highest mobility level.
Collapse
|
|
47
|
Masich AM, Heavner MS, Gonzales JP, Claeys KC. Pharmacokinetic/Pharmacodynamic Considerations of Beta-Lactam Antibiotics in Adult Critically Ill Patients. Curr Infect Dis Rep 2018; 20:9. [PMID: 29619607 DOI: 10.1007/s11908-018-0613-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW Beta-lactam antibiotics are commonly prescribed in critically ill patients for a variety of infectious conditions. Our understanding of how critical illness alters beta-lactam pharmacokinetics/pharmacodynamics (PK/PD) is rapidly evolving. RECENT FINDINGS There is a growing body of literature in adult patients demonstrating that physiological alterations occurring in critically ill patients may limit our ability to optimally dose beta-lactam antibiotics to reach these PK/PD targets. These alterations include changes in volume of distribution and renal clearance with multiple, often overlapping causative pathways, including hypoalbuminemia, renal replacement therapy, and extracorporeal membrane oxygenation. Strategies to overcome these PK alterations include extended infusions and therapeutic drug monitoring. Combined data has demonstrated a possible survival benefit associated with extending beta-lactam infusions in critically ill adult patients. This review highlights research on physiological derangements affecting beta-lactam concentrations and strategies to optimize beta-lactam PK/PD in critically ill adults.
Collapse
Affiliation(s)
- Anne M Masich
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Jeffrey P Gonzales
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.
| |
Collapse
|
|
48
|
Yang CY, Chen CS, Yiang GT, Cheng YL, Yong SB, Wu MY, Li CJ. New Insights into the Immune Molecular Regulation of the Pathogenesis of Acute Respiratory Distress Syndrome. Int J Mol Sci 2018; 19:ijms19020588. [PMID: 29462936 PMCID: PMC5855810 DOI: 10.3390/ijms19020588] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/11/2018] [Accepted: 02/14/2018] [Indexed: 12/11/2022] Open
Abstract
Acute respiratory distress syndrome is an inflammatory disease characterized by dysfunction of pulmonary epithelial and capillary endothelial cells, infiltration of alveolar macrophages and neutrophils, cell apoptosis, necroptosis, NETosis, and fibrosis. Inflammatory responses have key effects on every phase of acute respiratory distress syndrome. The severe inflammatory cascades impaired the regulation of vascular endothelial barrier and vascular permeability. Therefore, understanding the relationship between the molecular regulation of immune cells and the pulmonary microenvironment is critical for disease management. This article reviews the current clinical and basic research on the pathogenesis of acute respiratory distress syndrome, including information on the microenvironment, vascular endothelial barrier and immune mechanisms, to offer a strong foundation for developing therapeutic interventions.
Collapse
Affiliation(s)
- Chin-Yao Yang
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan.
| | - Chien-Sheng Chen
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Yeung-Leung Cheng
- Division of Thoracic Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- School of Surgery, Tzu Chi University, Hualien 970, Taiwan.
| | - Su-Boon Yong
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Show Chwan Memorial Hospital, Changhua 500, Taiwan.
- Department of Nursing, Meiho University, Pingtung 912, Taiwan.
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Chia-Jung Li
- Research Assistant Center, Show Chwan Memorial Hospital, Changhua 500, Taiwan.
| |
Collapse
|
|
49
|
Solari D, Miroz JP, Oddo M. Opening a Window to the Injured Brain: Non-invasive Neuromonitoring with Quantitative Pupillometry. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [DOI: 10.1007/978-3-319-73670-9_38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
|
50
|
Charlesworth M, Ashworth AD, Barker JM. Decision-making in response to respiratory veno-venous extracorporeal membrane oxygenation referrals: is current practice precise enough? Anaesthesia 2017; 73:154-159. [DOI: 10.1111/anae.14155] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia; University Hospital South Manchester; Manchester UK
| | - A. D. Ashworth
- Department of Cardiothoracic Anaesthesia; University Hospital South Manchester; Manchester UK
| | - J. M. Barker
- Department of Cardiothoracic Anaesthesia; University Hospital South Manchester; Manchester UK
| |
Collapse
|