51
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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52
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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53
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Hoyler MM, Flynn B, Iannacone EM, Jones MM, Ivascu NS. Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:2776-2792. [DOI: 10.1053/j.jvca.2019.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/04/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022]
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54
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Flower L, Madhivathanan PR, Andorka M, Olusanya O, Roshdy A, Sanfilippo F. Getting the most from the subcostal view: The rescue window for intensivists. J Crit Care 2020; 63:202-210. [PMID: 32958350 DOI: 10.1016/j.jcrc.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Luke Flower
- Department of Anaesthesia, University College London Hospitals NHS Trust, London, United Kingdom.
| | - Pradeep R Madhivathanan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Matyas Andorka
- Department of Critical Care, Surrey and Sussex Healthcare NHS Trust, London, United Kingdom
| | - Olusegun Olusanya
- Department of Critical Care, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ashraf Roshdy
- Department of Critical Care, Whipps Cross University Hospital, Barts Health NHS Trust, London, United Kingdom; Critical Care Medicine department, Alexandria University, Alexandria, Egypt
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, AOU Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
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55
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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: 4.0] [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
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56
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Chow SY, Hwang NC. Update on anesthesia management for explantation of veno-arterial extracorporeal membrane oxygenation in adult patients. Ann Card Anaesth 2020; 22:422-429. [PMID: 31621679 PMCID: PMC6813703 DOI: 10.4103/aca.aca_178_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The utilization of temporary circulatory support in the form of extracorporeal membrane oxygenation (ECMO) has increased and its indications are expanding. Anesthesiologists may be involved in the care of these patients during the initiation of and weaning off from ECMO, surgical procedures with an ECMO in situ, and transfer of patients on ECMO between the operating theater and intensive care unit. This article addresses the anesthetic considerations and management for explant of veno-arterial ECMO in adults.
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Affiliation(s)
- Sau Yee Chow
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
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57
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Teran F, Burns KM, Narasimhan M, Goffi A, Mohabir P, Horowitz JM, Yuriditsky E, Nagdev A, Panebianco N, Chin EJ, Gottlieb M, Koenig S, Arntfield R. Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic. J Am Soc Echocardiogr 2020; 33:1040-1047. [PMID: 32600742 PMCID: PMC7245221 DOI: 10.1016/j.echo.2020.05.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside. METHODS A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic. RESULTS Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination. CONCLUSIONS In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.
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Affiliation(s)
- Felipe Teran
- Division of Emergency Ultrasound and Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Katharine M Burns
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois; University of Illinois at Chicago, Chicago, Illinois
| | - Mangala Narasimhan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Alberto Goffi
- Li Ka Shing Knowledge Institute, Department of Critical Care Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Mohabir
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Eugene Yuriditsky
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Arun Nagdev
- Division of Emergency Ultrasound, Department of Emergency Medicine, Highland General Hospital, Oakland, California
| | - Nova Panebianco
- Division of Emergency Ultrasound, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric J Chin
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Seth Koenig
- Division of Pulmonary, Department of Medicine, Albert Einstein School of Medicine, Bronx, New York
| | - Robert Arntfield
- Division of Critical Care Medicine, Department of Medicine, Victoria Hospital, Critical Care Trauma Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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58
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Park NH, Lashin H, Spiritoso R. Fulminant myocarditis: use of echocardiography from diagnosis to treatment. Echo Res Pract 2020; 7:K21-K26. [PMID: 32698157 PMCID: PMC7424325 DOI: 10.1530/erp-20-0005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/20/2020] [Indexed: 11/08/2022] Open
Abstract
Summary Fulminant myocarditis can present with life-threatening arrhythmias and cardiogenic shock due to ventricular failure. The diagnosis of myocarditis usually requires histological and immunological information, as its aetiology may be infectious (viral or non-viral), autoimmune or drug related. The treatment of fulminant myocarditis depends on the underlying cause but usually includes high dose systemic steroids as well as physiological support. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) can be used to support patients as a bridge to recovery by supporting biventricular function and decompressing the heart. V-A ECMO carries risks and complications of its own such as thrombus formation or bleeding. Different diagnostic modalities, such as transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE), are central to the monitoring of progression of disease and recovery of heart function. This case highlights the importance of early recognition and early support with V-A ECMO in fulminant myocarditis, as well as the role of repeated echocardiography when weaning from physiological support. Learning points:
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Affiliation(s)
- Na Hyun Park
- N Park, Intensive Care , Barts and The London NHS Trust, London, E1 1RD, United Kingdom of Great Britain and Northern Ireland
| | - Hazem Lashin
- H Lashin, Intensive Care, Barts and The London NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Rosalba Spiritoso
- R Spiritoso, Intensive Care, Barts and The London NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
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59
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Janus SE, Hajjari J, Al-Kindi S, Elgudin Y, Hoit BD. Contrast-enhanced echocardiographic detection of severe aortic insufficiency in venoarterial extracorporeal membrane oxygenation. Echocardiography 2020; 37:905-907. [PMID: 32511801 DOI: 10.1111/echo.14752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/30/2022] Open
Abstract
Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support is an increasingly used temporizing therapy for patients with refractory cardiogenic shock. Contrast-enhanced echocardiography plays a critical role in the diagnosis and management of diseases that precipitate severe cardiac failure. In this case report, we describe a previously healthy 60-year-old woman who presented with dyspnea on exertion, and whose hospital course was complicated by ventricular fibrillation, emergent coronary artery bypass surgery (CABG), and ECMO support. Her contrast-enhanced ECMO images demonstrated a unique pattern of opacification of three of the four cardiac chambers, which led to a diagnosis of severe aortic insufficiency.
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Affiliation(s)
- Scott E Janus
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Jamal Hajjari
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Sadeer Al-Kindi
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Yakov Elgudin
- Department of Surgery, Division of Cardiac Surgery, Case Western Reserve University, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brian D Hoit
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA.,Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020; 33:692-734. [PMID: 32503709 DOI: 10.1016/j.echo.2020.03.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.
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Affiliation(s)
| | | | - Niv Ad
- White Oak Medical Center and University of Maryland, Silver Spring, Maryland
| | - Alan Finley
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Feroze Mahmood
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Bradley Taylor
- University of Maryland Medical Center, Baltimore, Maryland
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61
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Su Y, Liu K, Zheng JL, Li X, Zhu DM, Zhang Y, Zhang YJ, Wang CS, SHI TT, Luo Z, Tu GW. Hemodynamic monitoring in patients with venoarterial extracorporeal membrane oxygenation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:792. [PMID: 32647717 PMCID: PMC7333156 DOI: 10.21037/atm.2020.03.186] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective mechanical circulatory support modality that rapidly restores systemic perfusion for circulatory failure in patients. Given the huge increase in VA-ECMO use, its optimal management depends on continuous and discrete hemodynamic monitoring. This article provides an overview of VA-ECMO pathophysiology, and the current state of the art in hemodynamic monitoring in patients with VA-ECMO.
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Affiliation(s)
- Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xin Li
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Du-Ming Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ying Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yi-Jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chun-Sheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Tian-Tian SHI
- Department of medicine, Yale New Haven Health/Bridgeport Hospital, Bridgeport, USA
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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62
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Hemodynamic Aspects of Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiac Support: A Worldwide Survey. ASAIO J 2020; 66:489-496. [DOI: 10.1097/mat.0000000000001024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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63
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Krishnan S, Schmidt GA. Hemodynamic monitoring in the extracorporeal membrane oxygenation patient. Curr Opin Crit Care 2020; 25:285-291. [PMID: 30865613 DOI: 10.1097/mcc.0000000000000602] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO). We emphasize tools to judge the adequacy of perfusion, predict the response to fluid boluses, measure right ventricular function, assess left ventricular distention (for VA ECMO), and monitor the process of weaning from ECMO. We emphasize how differences between VV ECMO and VA ECMO are reflected in distinct approaches to monitoring. RECENT FINDINGS Point-of-care ultrasound and near-infrared spectroscopy can play a significant role in monitoring of global and regional perfusion. SUMMARY Recent literature in hemodynamic monitoring of ECMO patients is discussed, with comparison of VV ECMO and VA ECMO. Many common monitoring tools lack validity during ECMO: by taking into account the unique physiology of the ECMO circulation, selected methods can aid in the care of these complex patients.
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Affiliation(s)
| | - Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
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64
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Gerstein NS, Freeman JJ, Mitchell JA, Cronin BH. Fatal pulmonary hemorrhage due to severe mitral regurgitation during venoarterial extracorporeal membrane oxygenation. Saudi J Anaesth 2020; 14:253-256. [PMID: 32317888 PMCID: PMC7164472 DOI: 10.4103/sja.sja_773_19] [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: 12/12/2019] [Accepted: 01/16/2020] [Indexed: 11/12/2022] Open
Abstract
Pulmonary hemorrhage (PH) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been primarily reported in pediatric patients. We report a case of fatal PH during VA-ECMO for cardiogenic shock after myocardial infarction (MI). PH, in this case, was secondary to a triad of aortic insufficiency, left ventricle distension, and severe laminar mitral regurgitation. This case scenario, previously unreported in adults, illustrates the need for the echocardiographic assessment of left-sided heart valves prior to VA-ECMO initiation after MI as well as management considerations for massive PH in this context.
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Affiliation(s)
- Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Joseph J Freeman
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jessica A Mitchell
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Brett H Cronin
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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65
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Viau-Lapointe J, Douflé G. Transthoracic View of Extracorporeal Membrane Oxygenation Cannulae. Am J Respir Crit Care Med 2020; 199:e39-e40. [PMID: 30571143 DOI: 10.1164/rccm.201806-1153im] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Julien Viau-Lapointe
- 1 Département de Médecine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada; and.,2 Interdepartmental Division of Critical Care Medicine, Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Ghislaine Douflé
- 2 Interdepartmental Division of Critical Care Medicine, Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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66
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Junyu MMD, Xiaoqing WMD, Lina ZMD, Jun DMD, Xiaoting WMD. Critical Care Ultrasound: A Necessary and Mandatory Tool for Novel Coro-navirus Pneumonia. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2020. [DOI: 10.37015/audt.2020.200040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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67
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Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:208-218. [DOI: 10.1053/j.jvca.2019.08.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/26/2019] [Accepted: 08/17/2019] [Indexed: 01/21/2023]
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68
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Contemporary Comprehensive Monitoring of Veno-arterial Extracorporeal Membrane Oxygenation Patients. Can J Cardiol 2019; 36:291-299. [PMID: 31924449 DOI: 10.1016/j.cjca.2019.10.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/17/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023] Open
Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) has increased substantially over the past few decades. Today's clinicians now have a powerful means with which to salvage a growing population of patients at risk for cardiopulmonary collapse. At the same time, patients supported with VA ECMO have become increasingly more complex. The successful use of VA ECMO depends not only on selecting the appropriate patients, but also on effectively navigating a potential torrent of device- and patient-related complications until ECMO is no longer needed. A multitude of monitoring tools are now available to help the treatment team determine the adequacy of care, to detect problems, and to anticipate recovery. Monitoring with devices such as the Swan-Ganz catheter, transthoracic and transesophageal echocardiography, chest radiography, and near-infrared spectroscopy can provide useful information to complement routine clinical care. Leveraging data derived from the ECMO circuit itself also can be instrumental in both evaluating the sufficiency of support and troubleshooting complications. Each of these tools, however, has its own unique sets of limitations and liabilities. A thorough understanding of these risks and benefits is critical to the contemporary care of the individual managed with VA ECMO. In addition, more research is needed to establish optimal evidence-based care pathways and best-practice principles for using these devices to improve patient outcomes.
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Strunina S, Hozman J, Ostadal P. The peripheral cannulas in extracorporeal life support. ACTA ACUST UNITED AC 2019; 64:127-133. [PMID: 29648990 DOI: 10.1515/bmt-2017-0107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 03/12/2018] [Indexed: 11/15/2022]
Abstract
Femoral cannulation is a minimally invasive method which is an alternative method for central cannulation. This review focuses on the parameters and features of the available peripheral cannulas. Nowadays there exist many peripheral cannulas in a variety of sizes, configurations and lengths to meet the specific needs of the patients. Modern cannulas are strong, thin-walled and one piece reinforced constructions. Furthermore, modern cannulas are manufactured from a biocompatible material and surface coatings are applied to the cannulas to reduce the activation of the clotting. When peripheral cannulas are applied, bleeding, thrombosis and hemolysis are the most common complications.
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Affiliation(s)
- Svitlana Strunina
- Faculty of Biomedical Engineering, Czech Technical University in Prague, Nám. Sítná 3105, 272 01Kladno, Czech Republic
| | - Jiri Hozman
- Faculty of Biomedical Engineering, Czech Technical University in Prague, Nám. Sítná 3105, 272 01Kladno, Czech Republic
| | - Petr Ostadal
- Cardiovascular Center, Na Homolce Hospital, Roentgenova 2/37, 15030 Prague, Czech Republic
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Kado Y, Miyamoto T, Fukamachi K, Karimov JH. Update on the management and associated challenges of adult patients treated with veno-arterial extracorporeal membrane oxygenation. Expert Rev Med Devices 2019; 16:483-491. [DOI: 10.1080/17434440.2019.1614439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Yuichiro Kado
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
| | - Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
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Ortoleva JP, Dalia AA, Fiedler AG, D'Alessandro D, Shelton K, Villavicencio M, Cudemus GA. Echocardiographic Assessment of Biventricular Function in 249 Patients During the Peri-Extracorporeal Membrane Oxygenation Period. J Cardiothorac Vasc Anesth 2019; 33:1325-1330. [DOI: 10.1053/j.jvca.2018.09.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Indexed: 11/11/2022]
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72
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Merkle J, Azizov F, Fatullayev J, Weber C, Maier J, Eghbalzadeh K, Sabashnikov A, Pfister R, Wahlers T, Michels G. Monitoring of adult patient on venoarterial extracorporeal membrane oxygenation in intensive care medicine. J Thorac Dis 2019; 11:S946-S956. [PMID: 31183174 DOI: 10.21037/jtd.2018.10.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Nowadays high-tech medical assist device therapy is a crucial part of intensive care medicine. Especially, management of circulatory assist device systems poses an increasing challenge for intensive care medicine. So far, autonomous recommendations for monitoring of extracorporeal life support systems in the form of guidelines or position papers are lacking. The purpose of this paper was to present an orientation guide on this important topic.
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Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Farid Azizov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Javid Fatullayev
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Johanna Maier
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Roman Pfister
- Department of Cardiology, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Guido Michels
- Department of Cardiology, University Hospital of Cologne, Cologne, Germany
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73
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Vieillard-Baron A, Millington SJ, Sanfilippo F, Chew M, Diaz-Gomez J, McLean A, Pinsky MR, Pulido J, Mayo P, Fletcher N. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med 2019; 45:770-788. [DOI: 10.1007/s00134-019-05604-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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74
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Gutsche JT, Ortoleva J. Echocardiography: Do We Need New Standards for ECMO Patients? J Cardiothorac Vasc Anesth 2019; 33:2356-2357. [PMID: 31060940 DOI: 10.1053/j.jvca.2019.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Jamel Ortoleva
- Department of Anesthesiology, Tufts Medical Center, Boston, MA
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75
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Harfi TT, Milks MW, Orsinelli DA, Raman SV, Abraham WT, Kahwash R. Imaging Device Therapy: Essentials for the Imager. Heart Fail Clin 2019; 15:305-320. [PMID: 30832820 DOI: 10.1016/j.hfc.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of patients with heart failure with reduced ejection fraction has evolved. Recently, a fully implantable remote hemodynamic monitoring sensor in the pulmonary artery was approved in the treatment of patients at risk of heart failure readmissions. Several novel devices designed to offload the left atrium by creating a small interatrial shunt are being investigated. Cardiac imaging plays a vital role in the selection process, implantation, and monitoring of individuals with such devices. This article discusses in detail various imaging techniques and key clinical points relating to several cardiac devices used in the treatment of patients with heart failure.
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Affiliation(s)
- Thura T Harfi
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA.
| | - Michael Wesley Milks
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - David A Orsinelli
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Subha V Raman
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - William T Abraham
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Rami Kahwash
- Division of Cardiology, Department of Medicine, The Ohio State University Wexner Medical Center, The Ohio State University, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
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76
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Mensch J, Flynn BC. Echocardiographic Assessment of Biventricular Function in 249 Patients During the Peri-Extracorporeal Membrane Oxygenation Period: Procedural and Ethical Questions. J Cardiothorac Vasc Anesth 2018; 33:1331-1333. [PMID: 30448071 DOI: 10.1053/j.jvca.2018.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jason Mensch
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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Winiszewski H, Perrotti A, Chocron S, Capellier G, Piton G. Malposition of the Extracorporeal Membrane Oxygenation Venous Cannula in an Accessory Hepatic Vein. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2018; 50:167-169. [PMID: 30250343 PMCID: PMC6146273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 04/06/2018] [Indexed: 06/08/2023]
Abstract
We report a case of a refractory cardiogenic shock secondary to myocardial infarction in a 70-year-old patient requiring femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). At initial transesophageal echocardiography, the venous cannula tip was seen in the inferior vena cava (IVC), but not in right atrium. On day 8, ultrasonic examination identified that the end of the venous cannula was in the hepatic vein (HV). Despite such malposition, no disturbance in extracorporeal membrane oxygenation (ECMO) venous return was observed. Moving or replacing the cannula was considered a high-risk maneuver potentially resulting in hepatic laceration with hemoperitoneum. Because of adequate venous drainage, allowing sufficient blood flow, venous cannula repositioning was delayed until day 10, when a ventricular defect was repaired and ECMO was weaned off. At the time of VA-ECMO implantation, the venous cannula has to be positioned in the right atrium using real time echo monitoring. Visualization of the guide wire in the IVC but not in the right atrium is insufficient to ensure appropriate venous cannula positioning. Indeed, either accidental catheterization or cannula migration into the HV is possible during ECMO. Health care professionals dealing with ECMO have to be aware of this possible malposition, to correct it and prevent insufficient venous drainage or traumatic complications.
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Affiliation(s)
| | - Andrea Perrotti
- Cardiac Surgery Unit, University Hospital, Besancon, France
- Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Sidney Chocron
- Cardiac Surgery Unit, University Hospital, Besancon, France
- Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Gilles Capellier
- Medical Intensive Care Unit
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia; and
- Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Gaël Piton
- Medical Intensive Care Unit
- Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
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Donker DW, Meuwese CL, Braithwaite SA, Broomé M, van der Heijden JJ, Hermens JA, Platenkamp M, de Jong M, Janssen JG, Balík M, Bělohlávek J. Echocardiography in extracorporeal life support: A key player in procedural guidance, tailoring and monitoring. Perfusion 2018; 33:31-41. [DOI: 10.1177/0267659118766438] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal life support (ECLS) is a mainstay of current practice in severe respiratory, circulatory or cardiac failure refractory to conventional management. The inherent complexity of different ECLS modes and their influence on the native pulmonary and cardiovascular system require patient-specific tailoring to optimize outcome. Echocardiography plays a key role throughout the ECLS care, including patient selection, adequate placement of cannulas, monitoring, weaning and follow-up after decannulation. For this purpose, echocardiographers require specific ECLS-related knowledge and skills, which are outlined here.
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Affiliation(s)
- Dirk W. Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Christiaan L. Meuwese
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sue A. Braithwaite
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michael Broomé
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden
| | - Joris J. van der Heijden
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeannine A. Hermens
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc Platenkamp
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michel de Jong
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jacqueline G.D. Janssen
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martin Balík
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Bělohlávek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Abstract
PURPOSE OF REVIEW An increasing number of patients are placed on extracorporeal membrane oxygenation (ECMO) for respiratory or cardiac failure. Sound understanding of physiology and configuration of ECMO is essential for proper management. This review covers different monitoring parameters and tools for patients supported with different types of ECMO. RECENT FINDINGS Emphasis is placed on monitoring saturations at different sites depending on type of ECMO support. The main monitoring tools detailed in this review are echocardiography and pulmonary artery catheters. SUMMARY The review will help physicians better assess adequate ECMO support by using the appropriate parameters for each type of configuration.
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80
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Ahn HJ, Lee JW, Joo KH, You YH, Ryu S, Lee JW, Kim SW. Point-of-Care Ultrasound–Guided Percutaneous Cannulation of Extracorporeal Membrane Oxygenation: Make it Simple. J Emerg Med 2018; 54:507-513. [DOI: 10.1016/j.jemermed.2017.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/13/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
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81
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Vignon P. What is new in critical care echocardiography? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:40. [PMID: 29467026 PMCID: PMC5822525 DOI: 10.1186/s13054-018-1970-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/31/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Philippe Vignon
- Medical-surgical intensive care unit, Dupuytren Teaching hospital, Limoges, France. .,INSERM Clinical Investigation Center 1435, Dupuytren Teaching hospital, Limoges, France. .,University of Limoges, Limoges, France.
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82
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Huang KC, Lin LY, Chen YS, Lai CH, Hwang JJ, Lin LC. Three-Dimensional Echocardiography–Derived Right Ventricular Ejection Fraction Correlates with Success of Decannulation and Prognosis in Patients Stabilized by Venoarterial Extracorporeal Life Support. J Am Soc Echocardiogr 2018; 31:169-179. [DOI: 10.1016/j.echo.2017.09.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 10/18/2022]
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83
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Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology 2018; 128:181-201. [DOI: 10.1097/aln.0000000000001887] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments of these conditions often require both manipulation of extracorporeal membrane oxygenation settings and physiologic interventions. Perioperative management of anticoagulation, as well as thresholds to transfuse blood products, remain highly controversial and must take into account the specific procedure, extracorporeal membrane oxygenation circuit function, and patient comorbidities. We will review the physiologic management of the patient requiring surgery while on venovenous extracorporeal membrane oxygenation.
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84
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Harvey C. Cannulation for Neonatal and Pediatric Extracorporeal Membrane Oxygenation for Cardiac Support. Front Pediatr 2018; 6:17. [PMID: 29616201 PMCID: PMC5868139 DOI: 10.3389/fped.2018.00017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/17/2018] [Indexed: 11/18/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) has increased over recent years providing respiratory and cardiac support. Optimal cannula placement is essential for successful patient outcomes. Multiple cannulation strategies may be employed depending on the age/weight of the patient and their underlying condition. This article discusses cannulation technique focusing on the cannulation of pediatric and neonatal patients for cardiac support on ECMO.
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Affiliation(s)
- Chris Harvey
- University Hospitals of Leicester, Leicester, United Kingdom
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85
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Perioperative management of a patient on VA-ECMO undergoing noncardiac surgery. Case report. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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86
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Riahi M, Baruteau AE. Left ventricular distention under venoarterial extracorporeal membrane oxygenation support: when should we consider percutaneous left heart decompression? J Thorac Dis 2017; 9:4919-4921. [PMID: 29312692 DOI: 10.21037/jtd.2017.11.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Mounir Riahi
- Department of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Alban-Elouen Baruteau
- Department of Congenital Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,M3C CHU de Nantes, Fédération des Cardiopathies Congénitales, Nantes, France.,IHU LIRYC, Electrophysiology and Heart Modeling Institute, Bordeaux, France
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87
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Anesthetic management of the patient with extracorporeal membrane oxygenator support. Best Pract Res Clin Anaesthesiol 2017; 31:227-236. [PMID: 29110795 DOI: 10.1016/j.bpa.2017.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/15/2017] [Accepted: 07/12/2017] [Indexed: 11/22/2022]
Abstract
The use of short-term mechanical circulatory support in the form of extracorporeal membrane oxygenation (ECMO) in adult patients has increased over the last decade. Cardiothoracic anesthesiologists may care for these patients during ECMO placement and for procedures while ECMO support is in place. An understanding of ECMO capabilities, indications, and complications is essential to the anesthesiologist caring for these patients. Below we review the anesthetic considerations for the implantation of ECMO and concerns when caring for patients on ECMO.
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88
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Zochios V, Roscoe A. Echocardiography as an Adjunct in Venovenous Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2017; 32:379-380. [PMID: 29126674 DOI: 10.1053/j.jvca.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Vasileios Zochios
- University Hospitals Birmingham NHS Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Perioperative Critical Care and Trauma Trials Group, Institute of Inflammation and Ageing Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK.
| | - Andrew Roscoe
- Department of Cardiothoracic Anesthesia and Critical Care Medicine, Papworth Hospital, NHS Foundation Trust, Papworth Everard, Cambridge, UK
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89
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90
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Garijo JM, Mashari A, Meineri M. Role of Transesophageal Echocardiography in General Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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91
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Differential Diagnosis of Alterations in Arterial Flow and Tissue Oxygenation on Venoarterial Extracorporeal Membrane Oxygenation. Int J Artif Organs 2017; 40:651-655. [DOI: 10.5301/ijao.5000642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2017] [Indexed: 11/20/2022]
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be life-saving in several clinical situations, but it is also one of the most invasive therapeutic procedures, with significant potential for life-threatening complications. Pulse pressure waves are typically very small or even absent at the onset of ECMO therapy, and will reappear with the improvement of cardiac function. A low pulse pressure may indicate low cardiac output due to heart failure during sustained ECMO support. A sudden loss of pulse pressure during ECMO therapy, however, may reveal complications like pericardial tamponade, hemothorax or pneumothorax. Near infrared spectroscopy (NIRS) has been shown to be useful in detecting cerebral and lower limb ischemic events during ECMO therapy and could furthermore improve differential diagnosis in the event pulsatility of the arterial pressure trace is lost. Methods We are reporting on 3 different complications of ECMO and their impact on arterial pulse pressure, arterial oxygen tension and regional tissue oxygenation measured by NIRS. Results Pericardial hematoma, overinflation of the lung, and tension pneumothorax may impede cardiac output during VA-ECMO and cause a loss of pulse pressure. Monitoring of regional tissue oxygenation using NIRS, in addition to arterial and mixed venous oxygen tension, may allow early recognition and treatment of ECMO complications. Conclusions Together with the appearance of a flat, non pulsatile arterial pressure trace as well as a reduction in mixed venous oxygen saturation the improvement of upper body rSO2 measured by NIRS enables timely recognition of complications that interfere with natural cardiac output during VA-ECMO.
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92
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Price S, Platz E, Cullen L, Tavazzi G, Christ M, Cowie MR, Maisel AS, Masip J, Miro O, McMurray JJ, Peacock WF, Martin-Sanchez FJ, Di Somma S, Bueno H, Zeymer U, Mueller C. Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure. Nat Rev Cardiol 2017; 14:427-440. [PMID: 28447662 PMCID: PMC5767080 DOI: 10.1038/nrcardio.2017.56] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.
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Affiliation(s)
- Susanna Price
- Royal Brompton &Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield St &Bowen Bridge Road, Herston, Queensland 4029, Australia
| | - Guido Tavazzi
- University of Pavia Intensive Care Unit 1st Department, Fondazione Policlinico IRCCS San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Klinikum Nürnberg, Prof.-Ernst-Nathan-Straße 1, 90419 Nürnberg, Germany
| | - Martin R Cowie
- Department of Cardiology, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, California 92161, USA
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral, Hospital Sant Joan Despí Moisès Broggi and Hospital General de l'Hospitalet, University of Barcelona, Grand Via de las Corts Catalanes 585, 08007 Barcelona, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic de Barcelona, Carrer de Villarroel 170, 08036 Barcelona, Spain
| | - John J McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Scurlock Tower, 1 Baylor Plaza, Houston, Texas 77030, USA
| | - F Javier Martin-Sanchez
- Emergency Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, Calle del Prof Martín Lagos, 28040 Madrid, Spain
| | - Salvatore Di Somma
- Emergency Department, Sant'Andrea Hospital, Faculty of Medicine and Psychology, LaSapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares and Department of Cardiology, Hospital 12 de Octubre, Avenida de Córdoba, 28041 Madrid, Spain
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen, Bremserstraße 79, 67063 Ludwigshafen am Rhein, Germany
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
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93
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Jayaraman AL, Cormican D, Shah P, Ramakrishna H. Cannulation strategies in adult veno-arterial and veno-venous extracorporeal membrane oxygenation: Techniques, limitations, and special considerations. Ann Card Anaesth 2017; 20:S11-S18. [PMID: 28074818 PMCID: PMC5299823 DOI: 10.4103/0971-9784.197791] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) refers to specific mechanical devices used to temporarily support the failing heart and/or lung. Technological advances as well as growing collective knowledge and experience have resulted in increased ECMO use and improved outcomes. Veno-arterial (VA) ECMO is used in selected patients with various etiologies of cardiogenic shock and entails either central or peripheral cannulation. Central cannulation is frequently used in postcardiotomy cardiogenic shock and is associated with improved venous drainage and reduced concern for upper body hypoxemia as compared to peripheral cannulation. These concerns inherent to peripheral VA ECMO may be addressed through so-called triple cannulation approaches. Veno-venous (VV) ECMO is increasingly employed in selected patients with respiratory failure refractory to more conventional measures. Newer dual lumen VV ECMO cannulas may facilitate extubation and mobilization. In summary, the pathology being addressed impacts the ECMO approach that is deployed, and each ECMO implementation has distinct virtues and drawbacks. Understanding these considerations is crucial to safe and effective ECMO use.
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Affiliation(s)
- Arun L Jayaraman
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic; Department of Critical Care Medicine, Mayo Clinic, Arizona, USA
| | - Daniel Cormican
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Allegheny General Hospital, Pennsylvania, USA
| | - Pranav Shah
- Department of Anesthesiology, Virginia Commonwealth University, Virginia, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, USA
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94
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Ait Hssain A. Management strategies on venovenous extracorporeal membrane oxygenation. Qatar Med J 2017. [PMCID: PMC5474584 DOI: 10.5339/qmj.2017.swacelso.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, P.O. Box 3050, Doha, Qatar
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95
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Monitorage hémodynamique par échocardiographie des patients en état de choc. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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96
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Affiliation(s)
- Poonam Malhotra Kapoor
- Chief Editor, ACA and Professor, Department of Cardiac Anaesthesia, CNC, AIIMS, New Delhi, India
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97
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Said MM, Rivera O, Mikesell GT, Rais-Bahrami K. Influence of central hemodynamics on VV ECMO oxygen delivery in neonatal animal model. J Neonatal Perinatal Med 2017; 10:139-145. [PMID: 28409759 DOI: 10.3233/npm-171692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Recirculation of oxygenated blood in venovenous extracorporeal membrane oxygenation (VV ECMO) can decrease the oxygen delivery provided by the ECMO support. This study investigated the influence of central hemodynamics and catheter position on the amount of recirculation and oxygen delivery during VV ECMO. METHODS Recirculation was measured in seven newborn lambs (mean weight 4.7 kg) during VV ECMO using the ELSA Monitor (Transonic Systems, Inc., Ithaca, NY) and using the central venous line (CVL) method. The ECMO pump was set at the prescribed flow of 110-120 mL/kg/min for a targeted oxygen delivery rate of 6cc/kg/min without recirculation. Hemodynamic status before and during ECMO was also measured by the COstatus Monitor (Transonic Systems, Inc.,Ithaca, NY). RESULTS Lambs with a higher cardiac index (>160 ml/min/kg), had a tendency to have higher percent oxygen delivery (65-94%, at prescribed flow) while lambs with lower cardiac index (<150 ml/min/kg), tended to have lower percent oxygen delivery (39-62%, at prescribed flow). ELSA recirculation measurements had a squared correlation coefficient R2 = 0.8 with the CVL method. CONCLUSIONS The ELSA monitor provides an easy to use, non-invasive method to measure recirculation in VV ECMO. The data suggests that cardiac function may play an important prognostic role in achieving effective VV ECMO support.
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Affiliation(s)
- M M Said
- Departments of Neonatology, Children's National Medical Center and The George Washington University School of Medicine, Washington, DC, USA
| | - O Rivera
- Biomedical Engineering, Children's National Medical Center and The George Washington University School of Medicine, Washington, DC, USA
| | - G T Mikesell
- Cardiovascular Surgery, Children's National Medical Center and The George Washington University School of Medicine, Washington, DC, USA
| | - K Rais-Bahrami
- Departments of Neonatology, Children's National Medical Center and The George Washington University School of Medicine, Washington, DC, USA
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98
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Zhang Z. Echocardiography for patients undergoing extracorporeal cardiopulmonary resuscitation: a primer for intensive care physicians. J Intensive Care 2017; 5:15. [PMID: 28168038 PMCID: PMC5288871 DOI: 10.1186/s40560-017-0211-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023] Open
Abstract
Echocardiography is an invaluable tool in the management of patients with extracorporeal cardiopulmonary resuscitation (ECPR) and subsequent extracorporeal membrane oxygenation (ECMO) support and weaning. At the very beginning, echocardiography can identify the etiology of cardiac arrest, such as massive pulmonary embolism and cardiac tamponade. Eliminating these culprits saves life and may avoid the initiation of extracorporeal cardiopulmonary resuscitation. If the underlying causes are not identified or intrinsic to the heart (e.g., such as those caused by cardiomyopathy and myocarditis), conventional cardiopulmonary resuscitation (CCPR) will continue to maintain cardiac output. The quality of CCPR can be monitored, and if cardiac output cannot be maintained, early institution of extracorporeal cardiopulmonary resuscitation may be reasonable. Cannulation is sometimes challenging for extracorporeal cardiopulmonary resuscitation patients. Fortunately, with the help of ultrasonography procedures including localization of vessels, selecting a cannula of appropriate size and confirmation of catheter tip may become easy under sophisticated hand. Monitoring of cardiac function and complications during extracorporeal membrane oxygenation support can be done with echocardiography. However, the cardiac parameters should be interpreted with understanding of hemodynamic configuration of extracorporeal membrane oxygenation. Thrombus and blood stasis can be identified with ultrasound, which may prompt mechanical and pharmacological interventions. The final step is extracorporeal membrane oxygenation weaning. A number of studies investigated the accuracy of some echocardiographic parameters in predicting success rate and demonstrated promising results. Parameters and threshold for successful weaning include aortic VTI ≥ 10 cm, LVEF > 20-25%, and lateral mitral annulus peak systolic velocity >6 cm/s. However, the effectiveness of echocardiography in ECPR patients cannot be determined in observational studies and requires randomized controlled trials in the future. The contents in this review are well known to echocardiography specialists; thus, it should be used as an educational material for emergency or intensive care physicians. There is a trend that focused echocardiography is performed by intensivists and emergency physicians.
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Affiliation(s)
- Zhongheng Zhang
- 0000 0004 1759 700Xgrid.13402.34Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, No 3, East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
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99
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Banfi C, Pozzi M, Siegenthaler N, Brunner ME, Tassaux D, Obadia JF, Bendjelid K, Giraud R. Veno-venous extracorporeal membrane oxygenation: cannulation techniques. J Thorac Dis 2016; 8:3762-3773. [PMID: 28149575 DOI: 10.21037/jtd.2016.12.88] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The development of extracorporeal membrane oxygenation (ECMO) technology allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in adult patients who are not responsive to conventional treatment. Current ECMO therapies provide a variety of options for the multidisciplinary teams who are involved in the management of these critically ill patients. In this regard, veno-venous ECMO (VV-ECMO) can provide quite complete respiratory support, even if this highly complex technique presents substantial risks, such as bleeding, thromboembolic events and infection. While VV-ECMO circuits usually include the cannulation of two vessels (double cannulation) in its classic configuration, the use of a single cannula is now possible for VV-ECMO support. Recently, experienced centers have employed more advanced approaches by cannulating three vessels (triple cannulation) which follows veno-arterio-venous (VAV) or veno-arterio-pulmonary-arterial cannulation (VAPa). However, 'triple' cannulation expands the field of application but increases the complexity of ECMO systems. In the present review, the authors focus on the indications for VV-ECMO, patient assessment prior to cannulation, the role of ultrasound-guided vessel puncture, double lumen single bicaval cannulations, and finally triple cannulation in VV-ECMO.
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Affiliation(s)
- Carlo Banfi
- Division of Cardiovascular Surgery, Geneva University Hospitals, Geneva, Switzerland;; Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, "Claude Bernard" University, Lyon, France
| | - Nils Siegenthaler
- Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland;; Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Marie-Eve Brunner
- Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Didier Tassaux
- Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, "Claude Bernard" University, Lyon, France
| | - Karim Bendjelid
- Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland;; Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
| | - Raphaël Giraud
- Faculty of Medicine, University of Geneva, Geneva, Switzerland;; Geneva Hemodynamic Research Group, Geneva, Switzerland;; Intensive Care Service, Geneva University Hospitals, Geneva, Switzerland
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100
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Baruteau AE, Barnetche T, Morin L, Jalal Z, Boscamp NS, Le Bret E, Thambo JB, Vincent JA, Fraisse A, Torres AJ. Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 7:70-79. [PMID: 27742755 DOI: 10.1177/2048872616675485] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aimed to assess whether balloon atrioseptostomy (BAS) is a safe and efficient strategy. METHODS All patients who underwent percutaneous static BAS under VA-ECMO at four tertiary institutions were retrospectively reviewed. RESULTS From 2000 to 2014, BAS was performed in 64 patients (32 adults and 32 children). Indications for ECMO support included acute myocarditis (31.3%) and non-myocarditis cardiac disease, mostly end-stage dilated cardiomyopathy (32.8%). BAS was required because of pulmonary oedema/haemorrhage and left ventricular (LV) distension. The mean balloon diameter was 21.8 ± 8.4mm. Adequate LA decompression was achieved in all patients. Mean LA pressure fell from 24.2 ± 6.9 mmHg to 7.8 ± 2.6 mmHg ( p < 0.001). The left-to-right atrial pressure gradient fell from 17.2 ± 7.1 mmHg to 0.09 ± 0.5 mmHg ( p < 0.001). Echocardiography showed an unrestrictive left-to-right atrial shunting in all patients. Improvement of day 1 chest X-ray was observed in 76.6% of patients, clinical status in 98.4% of patients and pulmonary haemorrhage in 14 out of 14 patients. Complications occurred in 9.4% of patients, representing pericardial effusion, fast atrial fibrillation, ventricular fibrillation requiring defibrillation, transient complete heart block and femoral venous dissection requiring covered stent placement. In the 37 (57.8%) patients who were successfully decannulated, the median ECMO duration was 9 (range: 4-24) days. After a median follow-up of 12.3 (range: 0.1-142) months, 35.9% patients died, 17.2% received a LV assist device as a bridge to transplantation, 31.2% were transplanted and 56.2% were home discharged and alive. CONCLUSIONS Percutaneous BAS may be a safe and efficient strategy for discharging the LA in both adults and children supported by VA-ECMO.
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Affiliation(s)
- Alban-Elouen Baruteau
- 1 Department of Paediatric Cardiology, Royal Brompton Hospital and Harefield NHS Foundation Trust, Imperial College London, London, UK.,2 Cardiology Clinical Academic Group, Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK.,3 IHU LIRYC, Electrophysiology and Heart Modeling Institute, INSERM U1045, Bordeaux, France
| | - Thomas Barnetche
- 4 Department of Rheumatology, University Hospital Pellegrin, Bordeaux, France
| | - Luc Morin
- 5 Department of Pediatric Intensive Care, Paris South University Hospitals, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Zakaria Jalal
- 3 IHU LIRYC, Electrophysiology and Heart Modeling Institute, INSERM U1045, Bordeaux, France.,6 Department of Pediatric Cardiology, Haut-Lévèque Hospital, Bordeaux University, Bordeaux, France
| | - Nicholas S Boscamp
- 7 Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Emmanuel Le Bret
- 8 Department of Pediatric Cardiac Surgery, Marie-Lannelongue Hospital, Paris, France
| | - Jean-Benoit Thambo
- 3 IHU LIRYC, Electrophysiology and Heart Modeling Institute, INSERM U1045, Bordeaux, France.,6 Department of Pediatric Cardiology, Haut-Lévèque Hospital, Bordeaux University, Bordeaux, France
| | - Julie A Vincent
- 7 Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Alain Fraisse
- 1 Department of Paediatric Cardiology, Royal Brompton Hospital and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - Alejandro J Torres
- 7 Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
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