101
|
Nee J, Koerner R, Zickler D, Schroeder T, Enghard P, Nibbe L, Hasper D, Buder R, Leithner C, Ploner CJ, Eckardt KU, Storm C, Kruse JM. Establishment of an extracorporeal cardio-pulmonary resuscitation program in Berlin - outcomes of 254 patients with refractory circulatory arrest. Scand J Trauma Resusc Emerg Med 2020; 28:96. [PMID: 32972428 PMCID: PMC7513459 DOI: 10.1186/s13049-020-00787-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/10/2020] [Indexed: 11/10/2022] Open
Abstract
Objective Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined. Design Prospective cohort study. Setting Tertiary referral university hospital center. Patients Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017. Intervention eCPR program for OHCA. Mesurements and main results A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR. State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol. Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p < 0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p < 0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality. Conclusion An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival.
Collapse
Affiliation(s)
- Jens Nee
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Roland Koerner
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lutz Nibbe
- Department of Emergency and Intensive Care Medicine, Ernst von Bergmann Klinikum, Charlottenstraße 72, 14467, Potsdam, Germany
| | - Dietrich Hasper
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Robert Buder
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jan M Kruse
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| |
Collapse
|
102
|
The Validity of SOFA Score to Predict Mortality in Adult Patients with Cardiogenic Shock on Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Res Pract 2020; 2020:3129864. [PMID: 32963830 PMCID: PMC7495164 DOI: 10.1155/2020/3129864] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/19/2020] [Indexed: 01/31/2023] Open
Abstract
Background Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital. Results One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p < 0.001), more haemodialysis use (p < 0.001), more gastrointestinal bleeding (p = 0.039), more ICH (p = 0.006), and fewer ICU days (p = 0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p < 0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p < 0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p < 0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p < 0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p < 0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p < 0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p < 0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p < 0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p = 0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock. Conclusion The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.
Collapse
|
103
|
Ohbe H, Ogura T, Matsui H, Yasunaga H. Extracorporeal cardiopulmonary resuscitation for acute aortic dissection during cardiac arrest: A nationwide retrospective observational study. Resuscitation 2020; 156:237-243. [PMID: 32800864 DOI: 10.1016/j.resuscitation.2020.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
AIM Acute aortic dissection (AAD) has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). However, studies are lacking regarding the epidemiology and effectiveness of ECPR for AAD. We aimed to examine whether ECPR for AAD during refractory cardiac arrest is effective. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified all emergently hospitalized adults who received ECPR on the day of admission and all AAD patients who received cardiopulmonary resuscitation on the day of admission. ECPR was defined as receiving both cardiopulmonary resuscitation and percutaneous extracorporeal membrane oxygenation. Outcomes were in-hospital mortality and neurological outcomes. We calculated the incremental cost-effectiveness ratio of ECPR for AAD. RESULTS We identified 398 AAD patients with ECPR, 9840 non-AAD patients with ECPR, and 9709 AAD patients with cardiopulmonary resuscitation but not ECPR. The incidence of AAD among the patients with ECPR on the day of admission was 3.9%. In-hospital mortality was 98% in AAD patients with ECPR, 79% in non-AAD patients with ECPR, and 98% in AAD patients with cardiopulmonary resuscitation but not ECPR. Seven AAD patients survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge. The incremental cost-effectiveness ratio of ECPR for AAD was estimated at 161,504 US dollars per quality-adjusted life year gained. CONCLUSION ECPR successfully improved outcomes and/or facilitated surgery for a small number of AAD patients with refractory cardiac arrest; however, the cost burden of ECPR for AAD patients may be unacceptably high.
Collapse
Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Takayuki Ogura
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Centre, Imperial Foundation SAISEIKAI, Utsunomiya Hospital, Tochigi, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| |
Collapse
|
104
|
Brandi G, Drewniak D, Buehler PK, Budilivschi A, Steiger P, Krones T. Indications and contraindications for extracorporeal life support for severe heart or lung failure: a systematic review. Minerva Anestesiol 2020; 87:199-209. [PMID: 32755087 DOI: 10.23736/s0375-9393.20.14513-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The effectiveness of extracorporeal life support (ECLS) in critically ill patients remains unclear despite a substantial increase in its use. This study critically assesses existing ECLS guidelines, consensus statements, and position papers to systematically review them for agreements and differences regarding indications and contraindications for ECLS. EVIDENCE ACQUISITION The aims of this review were to identify available indications and contraindications for ECLS and to evaluate the quality of the evidence on which they are based. Documents containing recommendations regarding indications and/or contraindications for ECLS in adults (aged 18+) were identified through Medline, EMBASE, and CENTRAL searches. Additional documents were identified from guideline-specific databases and the internet websites of professional societies. Based on the Appraisal of Guidelines for Research and Evaluation (AGREE II), four independent reviewers assessed the rigor of development and quality of the documents. EVIDENCE SYNTHESIS Eleven documents met the inclusion criteria. Three documents received an average score of ≥50% in all domains. However, the Editorial independence domain only scored <50% in most of the documents. Overall, 13 cardiac and 13 pulmonary ECLS indications, and 23 cardiac and 14 pulmonary contraindications were identified. Indications and contraindications for ECLS use are variable across the documents included and leave considerable room for interpretation. CONCLUSIONS The documents included for review show considerable variability, with little consensus on indications and contraindications. This lack of consensus may reflect a lack of clarity regarding ECLS utility. Additionally, it may reveal the necessity for individualized, patient-dependent criteria supported by the best evidence available.
Collapse
Affiliation(s)
- Giovanna Brandi
- Institute of Intensive Medicine, Zurich University Hospital, University of Zurich, Zurich, Switzerland -
| | - Daniel Drewniak
- Institute of Biomedical Ethics and History of Medicine, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp K Buehler
- Institute of Intensive Medicine, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | - Ana Budilivschi
- Institute of Biomedical Ethics and History of Medicine, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | - Peter Steiger
- Institute of Intensive Medicine, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | - Tanja Krones
- Clinical Ethics Unit, Institute of Biomedical Ethics and History of Medicine, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
105
|
Ballesteros Sanz MÁ, Hernández-Tejedor A, Estella Á, Jiménez Rivera JJ, González de Molina Ortiz FJ, Sandiumenge Camps A, Vidal Cortés P, de Haro C, Aguilar Alonso E, Bordejé Laguna L, García Sáez I, Bodí M, García Sánchez M, Párraga Ramírez MJ, Alcaraz Peñarrocha RM, Amézaga Menéndez R, Burgueño Laguía P. [Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)]. Med Intensiva 2020; 44:371-388. [PMID: 32360034 PMCID: PMC7142677 DOI: 10.1016/j.medin.2020.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 01/08/2023]
Abstract
On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.
Collapse
Affiliation(s)
- M Á Ballesteros Sanz
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
| | | | - Á Estella
- Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, España
| | - J J Jiménez Rivera
- Servicio de Medicina Intensiva, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
| | | | - A Sandiumenge Camps
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - P Vidal Cortés
- Servicio de Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, España
| | - C de Haro
- Servicio de Medicina Intensiva, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España; Servicio de Medicina Intensiva, CIBERES Enfermedades Respiratorias, Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - E Aguilar Alonso
- Servicio de Medicina Intensiva, Hospital Infanta Margarita, Cabra, Córdoba, España
| | - L Bordejé Laguna
- Servicio de Medicina Intensiva, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - I García Sáez
- Servicio de Medicina Intensiva, Hospital Universitario Donostia, San Sebastián, España
| | - M Bodí
- Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII, Tarragona, España
| | - M García Sánchez
- Servicio de Medicina Intensiva, Hospital Universitario Virgen Macarena, Sevilla, España
| | - M J Párraga Ramírez
- Servicio de Medicina Intensiva, Hospital General Universitario Morales Meseguer, Murcia, España
| | | | - R Amézaga Menéndez
- Servicio de Medicina Intensiva, Hospital Universitari Son Espases, Palma, Islas Baleares, España
| | - P Burgueño Laguía
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| |
Collapse
|
106
|
Miraglia D, Miguel LA, Alonso W. Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: systematic review and meta-analysis of propensity score-matched cohort studies. J Am Coll Emerg Physicians Open 2020; 1:342-361. [PMID: 33000057 PMCID: PMC7493557 DOI: 10.1002/emp2.12091] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In this systematic review and meta-analysis of propensity score-matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30-day and long-term favorable neurological outcomes and survival in patients resuscitated from in- and out-of-hospital cardiac arrest. METHODS We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Six cohort studies using propensity score-matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30-day and long-term favorable neurological outcome in adults compared to CCPR for in- and out-of-hospital cardiac arrest (RR = 2.02, 95% CI = 1.29-3.16; I2 = 20%, P = 0.002; very low-quality evidence) and (RR = 2.86, 95% CI = 1.64-5.01; I2 = 0%, P = 0.0002; moderate-quality evidence), respectively. When we analyzed in- and out-of-hospital cardiac arrest separately, ECPR was likely associated with improved 30-day favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.18, 95% CI = 1.24-3.81; I2 = 9%, P = 0.006; very low-quality evidence), but not for out-of-hospital cardiac arrest (RR = 2.61, 95% CI = 0.56-12.20; I2 = 59%, P = 0.22; very low-quality evidence). ECPR was also likely associated with improved long-term favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.50, 95% CI = 1.33-4.71; I2 = 0%, P = 0.005; moderate-quality evidence) and out-of-hospital cardiac arrest (RR = 4.64, 95% CI = 1.41-15.25; I2 = 0%, P = 0.01; moderate-quality evidence). CONCLUSIONS Our analysis suggests that VA-ECMO used as ECPR may improve long-term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well-designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.
Collapse
Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Lourdes A Miguel
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Wilfredo Alonso
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| |
Collapse
|
107
|
Ballesteros Sanz M, Hernández-Tejedor A, Estella Á, Jiménez Rivera J, González de Molina Ortiz F, Sandiumenge Camps A, Vidal Cortés P, de Haro C, Aguilar Alonso E, Bordejé Laguna L, García Sáez I, Bodí M, García Sánchez M, Párraga Ramírez M, Alcaraz Peñarrocha R, Amézaga Menéndez R, Burgueño Laguía P. Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19). MEDICINA INTENSIVA (ENGLISH EDITION) 2020. [PMCID: PMC7340388 DOI: 10.1016/j.medine.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.
Collapse
|
108
|
Pugh A, Tonna JE, Youngquist S, Ryan JJ, Brant‐Zawadzki G. Emergency department extracorporeal membrane oxygenation as a rescue therapy for ventricular tachycardia electrical storm: a case report. J Am Coll Emerg Physicians Open 2020; 1:371-374. [PMID: 33000059 PMCID: PMC7493577 DOI: 10.1002/emp2.12053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 11/11/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy is a cause of sudden cardiac death in often otherwise healthy young adults. Cardiac arrest following an unstable tachydysrhythmia may be the primary presenting symptom. Venous arterial extracorporeal life support via extracorporeal membrane oxygenation (VA ECMO) has been used as a rescue strategy in emergency departments (EDs) for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. We present a case of a previously healthy 18-year-old male who presented to our emergency department with ECG features of arrhythmogenic right ventricular cardiomyopathy and subsequent pulseless polymorphic ventricular tachycardia refractory cardiac arrest, treated with ED-initiated VA ECMO.
Collapse
Affiliation(s)
- Andrew Pugh
- Division of Emergency MedicineDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtah
| | - Joseph E. Tonna
- Division of Emergency MedicineDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtah
- Division of Cardiothoracic SurgeryDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtah
| | - Scott Youngquist
- Division of Emergency MedicineDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtah
| | - John J. Ryan
- Division of Cardiovascular MedicineUniversity of Utah HealthSalt Lake CityUtah
| | - Graham Brant‐Zawadzki
- Division of Emergency MedicineDepartment of SurgeryUniversity of Utah HealthSalt Lake CityUtah
| |
Collapse
|
109
|
Worku E, Gill D, Brodie D, Lorusso R, Combes A, Shekar K. Provision of ECPR during COVID-19: evidence, equity, and ethical dilemmas. Crit Care 2020; 24:462. [PMID: 32718340 PMCID: PMC7384274 DOI: 10.1186/s13054-020-03172-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/12/2020] [Indexed: 12/18/2022] Open
Abstract
The use of extracorporeal cardiopulmonary resuscitation (ECPR) to restore circulation during cardiac arrest is a time-critical, resource-intensive intervention of unproven efficacy. The current COVID-19 pandemic has brought additional complexity and significant barriers to the ongoing provision and implementation of ECPR services. The logistics of patient selection, expedient cannulation, healthcare worker safety, and post-resuscitation care must be weighed against the ethical considerations of providing an intervention of contentious benefit at a time when critical care resources are being overwhelmed by pandemic demand.
Collapse
Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- University of Queensland, Brisbane, Queensland, Australia.
| | - Denzil Gill
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Daniel Brodie
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Universités, UPMC Univ Paris 06, 75651, Paris Cedex 13, France
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
- Bond University, Gold Coast, Queensland, Australia
- Critical Care Research Group and Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, Australia
| |
Collapse
|
110
|
Fulcher BJ, Nicholson AJ, Linke NJ, Berkovic D, Hodgson CL, Anderson S, Bailey MJ, Bernard S, Board JV, Brodie D, Buhr H, Burrell AJC, Cooper DJ, Fan E, Fraser JF, Gattas DJ, Higgins AM, Hopper IK, Huckson S, Litton E, McGuinness SP, Nair P, Orford N, Parke RL, Pellegrino VA, Pilcher DV, Reddi BAJ, Stub D, Trapani T, Udy AA. The perceived barriers and facilitators to implementation of ECMO services in acute hospitals. Intensive Care Med 2020; 46:2115-2117. [DOI: 10.1007/s00134-020-06187-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
|
111
|
Koen 'J, Nathanaël T, Philippe D. A systematic review of current ECPR protocols. A step towards standardisation. Resusc Plus 2020; 3:100018. [PMID: 34223301 PMCID: PMC8244348 DOI: 10.1016/j.resplu.2020.100018] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/25/2022] Open
Abstract
Aim Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Our goal was to identify the best protocol for survival with good neurological outcome through the evaluation of current inclusion criteria, exclusion criteria, cannulation strategies and additional therapeutic measures. Methods A systematic literature search was used to identify eligible publications from PubMed, Embase, Web of Science and Cochrane for articles published from 29 June 2009 until 29 June 2019. Results The selection process led to a total of 24 eligible articles, considering 1723 patients in total. A good neurological outcome at hospital discharge was found in 21.3% of all patients. The most consistent criterion for inclusion was refractory cardiac arrest (RCA), used in 21/25 (84%) of the protocols. The preferred cannulation method was the percutaneous Seldinger technique (44%). Conclusion ECPR is a feasible option for cardiac arrest and should already be considered in an early stage of CPR. One of the key findings is that time-to-ECPR seems to be correlated with good neurological survival. An important contributing factor is the definition of RCA. Protocols defining RCA as >10 min had a mean good neurological survival of 26.7%. Protocols with a higher cut-off, between 15 and 30 min, had a mean good neurological survival of 14.5%. Another factor contributing to the time-to-ECPR is the preferred access technique. A percutaneous Seldinger technique combined with ultrasonography and fluoroscopic guidance leads to a reduced cannulation time and complication rate. Conclusive research around prehospital cannulation still needs to be conducted.
Collapse
Affiliation(s)
- 't Joncke Koen
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium.,KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Thelinge Nathanaël
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium.,KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Dewolf Philippe
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium.,KULeuven, Department of Public Health and Primary Care, Leuven, Belgium.,KULeuven, Faculty of Medicine, Leuven, Belgium
| |
Collapse
|
112
|
Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396:199-212. [PMID: 32682486 DOI: 10.1016/s0140-6736(20)31047-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.
Collapse
Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Höpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Höpitaux de Paris, Institut de Cardiologie, Paris, France.
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
113
|
Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers. ASAIO J 2020; 66:707-721. [PMID: 32604322 PMCID: PMC7228451 DOI: 10.1097/mat.0000000000001193] [Citation(s) in RCA: 249] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.
Collapse
|
114
|
Wang H, Hou D, Tian X, Wang L, Li C, Jia M, Hou X. Risk factors for agitation and hyperactive delirium in adult postcardiotomy patients with extracorporeal membrane oxygenation support: an observational study. Perfusion 2020; 35:534-542. [PMID: 32627668 DOI: 10.1177/0267659120937549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Agitation and delirium in critically ill patients after cardiac surgery carry poor in-hospital prognosis. Identifying risk factors may promote its prevention and management. Accordingly, this study aimed to evaluate the incidence of agitation and hyperactive delirium in postcardiotomy patients during the extracorporeal membrane oxygenation support and to identify the risk factors for its development. METHODS This single center, retrospective study was conducted at Beijing Anzhen Hospital, Capital Medical University. Data were extracted from the prospective institutional registry database of extracorporeal membrane oxygenation patients. Univariate and multivariate logistic regression analyses were performed to predict risk factors. RESULTS A total of 170 consecutive adult patients underwent extracorporeal membrane oxygenation in our hospital from January 2016 to December 2017. Ninety-four patients were included in the final analysis. The incidence of agitation and hyperactive delirium was 35% in our population of extracorporeal membrane oxygenation-supported postcardiotomy patients. Agitation and delirium usually occurred within the first 3 days of extracorporeal membrane oxygenation. Multivariable analysis showed that history of previous stroke (without preoperative cognitive dysfunction; odds ratio, 4.425, 95% confidence interval: 1.171-16.716; p = 0.028) and mean arterial pressure reduction (before extracorporeal membrane oxygenation initiation) ⩾ 49 mmHg (odds ratio, 7.570, 95% confidence interval: 2.366-24.219, p = 0.001) were independent risk factors for agitation and hyperactive delirium during extracorporeal membrane oxygenation support. The areas under the receiver operating characteristic curve for the prediction of agitation and hyperactive delirium was 0.704 (95% confidence interval 0.589-0.820, p = 0.001). There was more severe arrhythmia in the agitation patients. CONCLUSION Our results suggest that the prevalence of agitation and hyperactive delirium in postcardiotomy patients with extracorporeal membrane oxygenation support is high. In addition, previous stroke and severe mean arterial pressure reduction before extracorporeal membrane oxygenation initiation is predictive of agitation and hyperactive delirium.
Collapse
Affiliation(s)
- Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dengbang Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaqiu Tian
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Jia
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
115
|
Gannon WD, Craig L, Netzel L, Mauldin C, Troutt A, Warhoover M, Tipograf Y, Hogrefe K, Rice TW, Shah A, Bacchetta M. Curriculum to Introduce Critical Care Nurses to Extracorporeal Membrane Oxygenation. Am J Crit Care 2020; 29:262-269. [PMID: 32607573 DOI: 10.4037/ajcc2020739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Despite the growing use of extracorporeal membrane oxygenation (ECMO) in intensive care units (ICUs), no standardized ECMO training pathways are available for ECMO-naive critical care nurses. OBJECTIVES To evaluate a critical care nurse ECMO curriculum that may be reproducible across institutions. METHODS An ECMO curriculum consisting of a basic safety course and an advanced user course was designed for critical care nurses. Courses incorporated didactic and simulation components, written knowledge examinations, and electronic modules. Differences in examination scores before and after each course for the overall cohort and for participants from each ICU type were analyzed with t tests or nonparametric equality-of-medians tests. Differences in postcourse scores across ICU types were examined with multiple linear regression. RESULTS Critical care nurses new to ECMO (n = 301) from various ICU types participated in the basic safety course; 107 nurses also participated in the advanced user course. Examination scores improved after completion of both courses for overall cohorts (P < .001 in all analyses). Median (interquartile range) individual score improvements were 23.1% (15.4%-38.5%) for the basic safety course and 8.4% (0%-16.7%) for the advanced user course. Postcourse written examination scores stratified by ICU type, compared with the medical ICU/cardiovascular ICU group (reference group), differed only in the neurovascular ICU group for the basic safety course (percent score difference, -3.0; 95% CI, -5.3 to -0.8; P = .01). CONCLUSIONS Implementation of an ECMO curriculum for a high volume of critical care nurses is feasible and effective.
Collapse
Affiliation(s)
- Whitney D. Gannon
- About the Authors: Whitney D. Gannon is director of ECMO quality and training, Lindsey Netzel is nurse educator in the medical intensive care unit (MICU), and Todd W. Rice is MICU director and a pulmonary and critical care attending physician, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne Craig
- Lynne Craig and Ashley Troutt are ECMO coordinators, Carmen Mauldin is a nurse educator in the cardiovascular ICU, Matthew Warhoover is a perfusionist, and Ashish Shah is director and chairman, Department of Cardiac Surgery, and codirector of the ECMO program, Vanderbilt University Medical Center
| | - Lindsey Netzel
- Lynne Craig and Ashley Troutt are ECMO coordinators, Carmen Mauldin is a nurse educator in the cardiovascular ICU, Matthew Warhoover is a perfusionist, and Ashish Shah is director and chairman, Department of Cardiac Surgery, and codirector of the ECMO program, Vanderbilt University Medical Center
| | - Carmen Mauldin
- Lynne Craig and Ashley Troutt are ECMO coordinators, Carmen Mauldin is a nurse educator in the cardiovascular ICU, Matthew Warhoover is a perfusionist, and Ashish Shah is director and chairman, Department of Cardiac Surgery, and codirector of the ECMO program, Vanderbilt University Medical Center
| | - Ashley Troutt
- Lynne Craig and Ashley Troutt are ECMO coordinators, Carmen Mauldin is a nurse educator in the cardiovascular ICU, Matthew Warhoover is a perfusionist, and Ashish Shah is director and chairman, Department of Cardiac Surgery, and codirector of the ECMO program, Vanderbilt University Medical Center
| | - Matthew Warhoover
- Lynne Craig and Ashley Troutt are ECMO coordinators, Carmen Mauldin is a nurse educator in the cardiovascular ICU, Matthew Warhoover is a perfusionist, and Ashish Shah is director and chairman, Department of Cardiac Surgery, and codirector of the ECMO program, Vanderbilt University Medical Center
| | - Yuliya Tipograf
- Yuliya Tipograf is a surgery resident at Vanderbilt University Medical Center and Columbia University Medical Center, New York, New York
| | - Katherine Hogrefe
- Katherine Hogrefe is an associate program manager, Department of Nursing Education and Professional Development, Vanderbilt University Medical Center
| | - Todd W. Rice
- About the Authors: Whitney D. Gannon is director of ECMO quality and training, Lindsey Netzel is nurse educator in the medical intensive care unit (MICU), and Todd W. Rice is MICU director and a pulmonary and critical care attending physician, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish Shah
- Lynne Craig and Ashley Troutt are ECMO coordinators, Carmen Mauldin is a nurse educator in the cardiovascular ICU, Matthew Warhoover is a perfusionist, and Ashish Shah is director and chairman, Department of Cardiac Surgery, and codirector of the ECMO program, Vanderbilt University Medical Center
| | - Matthew Bacchetta
- Matthew Bacchetta is an attending physician in the Department of Thoracic Surgery and co-director of the ECMO program at Vanderbilt University Medical Center
| |
Collapse
|
116
|
Chieffo A, Stefanini GG, Price S, Barbato E, Tarantini G, Karam N, Moreno R, Buchanan GL, Gilard M, Halvorsen S, Huber K, James S, Neumann FJ, Möllmann H, Roffi M, Tavazzi G, Ferré JM, Windecker S, Dudek D, Baumbach A. EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic. EUROINTERVENTION 2020; 16:233-246. [PMID: 32404302 DOI: 10.4244/eijy20m05_01] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to healthcare worldwide. The infection can be life threatening and require intensive care treatment. The transmission of the disease poses a risk to both patients and healthcare workers. The number of patients requiring hospital admission and intensive care may overwhelm health systems and negatively affect standard care for patients presenting with conditions needing emergency interventions. This position statements aims to assist cardiologists in the invasive management of acute coronary syndrome (ACS) patients in the context of the COVID-19 pandemic. To that end, we assembled a panel of interventional cardiologists and acute cardiac care specialists appointed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and from the Acute Cardiovascular Care Association (ACVC) and included the experience from the first and worst affected areas in Europe. Modified diagnostic and treatment algorithms are proposed to adapt evidence-based protocols for this unprecedented challenge. Various clinical scenarios, as well as management algorithms for patients with a diagnosed or suspected COVID-19 infection, presenting with ST- and non-ST-segment elevation ACS are described. In addition, we address the need for re-organization of ACS networks, with redistribution of hub and spoke hospitals, as well as for in-hospital reorganization of emergency rooms and cardiac units, with examples coming from multiple European countries. Furthermore, we provide a guidance to reorganization of catheterization laboratories and, importantly, measures for protection of healthcare providers involved with invasive procedures.
Collapse
Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
117
|
Salna M, Abrams D, Brodie D. Physical rehabilitation in the awake patient receiving extracorporeal circulatory or gas exchange support. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:834. [PMID: 32793679 PMCID: PMC7396238 DOI: 10.21037/atm.2020.03.151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intensive care unit (ICU)-acquired weakness is a common and serious sequela of critical illness. There is a growing body of evidence supporting the use of early mobilization in the ICU to mitigate this adverse effect. Recent data suggest that such a strategy may be feasible in patients with the most severe forms of cardiopulmonary failure—those requiring temporary mechanical circulatory support (TCS) or extracorporeal life support (ECLS). Both the modality of mechanical support and patient-specific characteristics must be taken into consideration when determining the appropriateness of an early mobilization strategy. The purpose of this review is to explore the current understanding of and evidence for mobilization and rehabilitation of patients receiving TCS or ECLS, including the identification of factors that may predict greater success for early mobilization and potential risks and contraindications to active physical therapy. While it is not yet known which of these patients are most likely to benefit from physical rehabilitation, a common theme is the importance of an interprofessional team approach to ensure patient safety and maximize the likelihood of successful mobilization.
Collapse
Affiliation(s)
- Michael Salna
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
118
|
Augoustides JG. Extracorporeal Membrane Oxygenation - Crucial Considerations during the Coronavirus Crisis. J Cardiothorac Vasc Anesth 2020; 34:1720-1722. [PMID: 32345529 PMCID: PMC7141443 DOI: 10.1053/j.jvca.2020.03.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 03/29/2020] [Indexed: 12/18/2022]
Affiliation(s)
- John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
119
|
The authors reply. Crit Care Med 2020; 48:e631-e632. [PMID: 32568915 DOI: 10.1097/ccm.0000000000004384] [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]
|
120
|
Hou X. Predicting short-term outcomes in patients supported with venoarterial extracorporeal membrane oxygenation. Perfusion 2020; 35:369-370. [PMID: 32558633 DOI: 10.1177/0267659120926945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
121
|
Multidisciplinary team approach in acute myocardial infarction patients undergoing veno-arterial extracorporeal membrane oxygenation. Ann Intensive Care 2020; 10:83. [PMID: 32548658 PMCID: PMC7296889 DOI: 10.1186/s13613-020-00701-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/11/2020] [Indexed: 01/31/2023] Open
Abstract
Background Limited data are available on the impact of a specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). This study evaluated whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients undergoing veno-arterial (VA) ECMO. Methods A total of 255 AMI patients who underwent VA-ECMO were included. In January 2014, a multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into a pre-ECMO team group (n = 131) and a post-ECMO team group (n = 124). The primary outcome was in-hospital mortality. Results In-hospital mortality (pre-ECMO team vs. post-ECMO team, 54.2% vs. 33.9%; p = 0.002) and cardiac intensive care unit mortality (pre-ECMO team vs. post-ECMO team, 51.9% vs. 30.6%; p = 0.001) were significantly lower after the implementation of a multidisciplinary ECMO team. On multivariable logistic regression model, implementation of the multidisciplinary ECMO team was associated with reduction of in-hospital mortality [odds ratio: 0.37, 95% confidence interval (CI) 0.20–0.67; p = 0.001]. Incidence of all-cause mortality [58.3% vs. 35.2%; hazard ratio (HR): 0.49, 95% CI 0.34–0.72; p < 0.001) and readmission due to heart failure (28.2% vs. 6.4%; HR: 0.21, 95% CI 0.08–0.58; p = 0.003) at 6 months of follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group. Conclusions Implementation of a multidisciplinary ECMO team was associated with improved clinical outcomes in AMI patients complicated by CS. Our data support that a specialized ECMO team is indispensable for improving outcomes in patients with AMI complicated by CS.
Collapse
|
122
|
Survival following venoarterial extracorporeal membrane oxygenation in postcardiotomy cardiogenic shock adults. Perfusion 2020. [PMID: 32529901 DOI: 10.1177/0267659120931306.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies reporting long-term outcomes of venoarterial extracorporeal membrane oxygenation-treated coronary artery bypass grafting patients are scarce. The objective of this study was to examine the survival outcomes and identify mortality risk factors for coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. METHODS Data from 121 consecutive venoarterial extracorporeal membrane oxygenation-treated coronary artery bypass grafting patients at the Beijing Anzhen Hospital between January 2012 and December 2016 were analyzed. Multivariable Cox regression modeling was used to identify factors independently associated with 36-month mortality. RESULTS Seventy-seven patients (64%) could be weaned from venoarterial extracorporeal membrane oxygenation, 56 patients (46%) survived to hospital discharge, and 41 patients (34%) survived to 36 months. Older age (hazard ratio, 1.06; 95% confidence interval [CI], 1.03-1.10; p < 0.001), left main coronary artery disease (hazard ratio, 1.64; 95% CI, 1.04-2.59; p < 0.001), and vasoactive inotropic score (hazard ratio, 1.09; 95% CI, 1.02-1.16; p = 0.011) were independent risk factors associated with 36-month mortality. The area under the receiver operating characteristic curve for the logistic regression model, which was constructed with three pre-extracorporeal membrane oxygenation parameters-age ⩾ 60 years, left main coronary artery disease, and vasoactive inotropic score > 60-was 0.87 (95% CI, 0.81-0.94). Age and left main coronary artery disease significantly increased the discriminatory performance of Sepsis-related Organ Failure Assessment score (0.79 vs. 0.91, p = 0.025). CONCLUSIONS Older age, left main coronary artery disease, and vasoactive inotropic score were associated with 36-month mortality in coronary artery bypass grafting patients who received venoarterial extracorporeal membrane oxygenation.
Collapse
|
123
|
Chen F, Wang L, Shao J, Wang H, Hou X, Jia M. Survival following venoarterial extracorporeal membrane oxygenation in postcardiotomy cardiogenic shock adults. Perfusion 2020; 35:747-755. [PMID: 32529901 PMCID: PMC7686926 DOI: 10.1177/0267659120931306] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Studies reporting long-term outcomes of venoarterial extracorporeal membrane
oxygenation–treated coronary artery bypass grafting patients are scarce. The
objective of this study was to examine the survival outcomes and identify
mortality risk factors for coronary artery bypass grafting patients who
received venoarterial extracorporeal membrane oxygenation for postcardiotomy
cardiogenic shock. Methods: Data from 121 consecutive venoarterial extracorporeal membrane
oxygenation–treated coronary artery bypass grafting patients at the Beijing
Anzhen Hospital between January 2012 and December 2016 were analyzed.
Multivariable Cox regression modeling was used to identify factors
independently associated with 36-month mortality. Results: Seventy-seven patients (64%) could be weaned from venoarterial extracorporeal
membrane oxygenation, 56 patients (46%) survived to hospital discharge, and
41 patients (34%) survived to 36 months. Older age (hazard ratio, 1.06; 95%
confidence interval [CI], 1.03-1.10; p < 0.001), left main coronary
artery disease (hazard ratio, 1.64; 95% CI, 1.04-2.59; p < 0.001), and
vasoactive inotropic score (hazard ratio, 1.09; 95% CI, 1.02-1.16;
p = 0.011) were independent risk factors associated with 36-month mortality.
The area under the receiver operating characteristic curve for the logistic
regression model, which was constructed with three pre–extracorporeal
membrane oxygenation parameters—age ⩾ 60 years, left main coronary artery
disease, and vasoactive inotropic score > 60—was 0.87 (95% CI,
0.81-0.94). Age and left main coronary artery disease significantly
increased the discriminatory performance of Sepsis-related Organ Failure
Assessment score (0.79 vs. 0.91, p = 0.025). Conclusions: Older age, left main coronary artery disease, and vasoactive inotropic score
were associated with 36-month mortality in coronary artery bypass grafting
patients who received venoarterial extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- Fei Chen
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Juanjuan Shao
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Jia
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
124
|
Heinsar S, Rozencwajg S, Suen J, Bassi GL, Malfertheiner M, Vercaemst L, Broman LM, Schmidt M, Combes A, Rätsep I, Fraser JF, Millar JE. Heart failure supported by veno-arterial extracorporeal membrane oxygenation (ECMO): a systematic review of pre-clinical models. Intensive Care Med Exp 2020; 8:16. [PMID: 32451698 PMCID: PMC7248156 DOI: 10.1186/s40635-020-00303-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used to treat patients with refractory severe heart failure. Large animal models are developed to help understand physiology and build translational research projects. In order to better understand those experimental models, we conducted a systematic literature review of animal models combining heart failure and VA-ECMO. STUDIES SELECTION A systematic review was performed using Medline via PubMed, EMBASE, and Web of Science, from January 1996 to January 2019. Animal models combining experimental acute heart failure and ECMO were included. Clinical studies, abstracts, and studies not employing VA-ECMO were excluded. DATA EXTRACTION Following variables were extracted, relating to four key features: (1) study design, (2) animals and their peri-experimental care, (3) heart failure models and characteristics, and (4) ECMO characteristics and management. RESULTS Nineteen models of heart failure and VA-ECMO were included in this review. All were performed in large animals, the majority (n = 13) in pigs. Acute myocardial infarction (n = 11) with left anterior descending coronary ligation (n = 9) was the commonest mean of inducing heart failure. Most models employed peripheral VA-ECMO (n = 14) with limited reporting. CONCLUSION Among models that combined severe heart failure and VA-ECMO, there is a large heterogeneity in both design and reporting, as well as methods employed for heart failure. There is a need for standardization of reporting and minimum dataset to ensure translational research achieve high-quality standards.
Collapse
Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia.,Second Department of Intensive Care, North Estonia Medical Centre, Talinn, Estonia
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia. .,Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia.
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia
| | - Maximilian Malfertheiner
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia.,Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, Louven, Belgium
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Matthieu Schmidt
- Second Department of Intensive Care, North Estonia Medical Centre, Talinn, Estonia
| | - Alain Combes
- Second Department of Intensive Care, North Estonia Medical Centre, Talinn, Estonia
| | - Indrek Rätsep
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia
| | - Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Chermside, Brisbane, Australia.,Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | |
Collapse
|
125
|
Core Outcome Measures for Research in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation for Acute Respiratory or Cardiac Failure: An International, Multidisciplinary, Modified Delphi Consensus Study. Crit Care Med 2020; 47:1557-1563. [PMID: 31389837 DOI: 10.1097/ccm.0000000000003954] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Research evaluating outcomes in critically ill patients with acute respiratory and cardiac failure supported with extracorporeal membrane oxygenation has increased significantly. The objective was to identify a core set of outcomes that are essential to include in all clinical research evaluating the use of either venoarterial or venovenous extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events. DESIGN A three-round modified Delphi process. SUBJECTS Patients, caregivers, multidisciplinary clinicians, researchers, industry partners, and research funders were included. SETTING Participants represented key extracorporeal membrane oxygenation organizations, including the Extracorporeal Life Support Organization, the International Extracorporeal Membrane Oxygenation Network, clinicians from high volume extracorporeal membrane oxygenation centers, and extracorporeal membrane oxygenation researchers or former extracorporeal membrane oxygenation patients from five continents. INTERVENTIONS We used recommended standards for the development of a core outcome set. Outcome measures identified from systematic reviews of the literature and from qualitative studies of survivors were mapped to the domains identified by the Core Outcome Measures in Effectiveness Trials initiative separately for venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS Participant response rates were 40 of 47 (85%), 35 of 37 (95%), and 64 of 69 (93%) for survey rounds 1, 2, and 3, respectively, with participants representing 10 different countries on five continents. After the third round survey, 8 outcome measures met consensus for both venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation. CONCLUSIONS This study identified core outcomes to assess in all research evaluating the use of extracorporeal membrane oxygenation, including adverse events specific to this intervention, permitting standardization of outcome reporting for the first time. Identifying appropriate measurement instruments to evaluate these outcomes is an important next step to enable synthesis of extracorporeal membrane oxygenation research.
Collapse
|
126
|
Burgos LM, Seoane L, Furmento JF, Costabel JP, Diez M, Vrancic M, Aissaoui N, Benzadón MN, Navia D. Effects of levosimendan on weaning and survival in adult cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation: systematic review and meta-analysis. Perfusion 2020; 35:484-491. [DOI: 10.1177/0267659120918473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Veno-arterial extracorporeal membrane oxygenation may be used to support patients with refractory cardiogenic shock. Many patients can be successfully weaned, the ability of some medications to facilitate weaning from veno-arterial extracorporeal membrane oxygenation were reported. To date, there are limited studies investigating the impact of levosimendan on veno-arterial extracorporeal membrane oxygenation weaning. The objective of this systematic review and meta-analysis was to assess the effects of levosimendan on successful weaning from veno-arterial extracorporeal membrane oxygenation and survival in adult patients with cardiogenic shock. Methods: We performed a systematic review and meta-analysis (PubMed, the Cochrane Library, and the International Clinical Trials Registry Platform published from the year 2000 onwards) investigating whether levosimendan offers advantages compared to standard therapy or placebo, in cardiogenic shock adult patients treated with veno-arterial extracorporeal membrane oxygenation. The primary outcome was veno-arterial extracorporeal membrane oxygenation successful weaning, whereas secondary outcome was all-cause mortality at the longest follow-up available. We pooled risk ratio and 95% confidence interval using fixed and random effects models according to the heterogeneity. Results: A total of five non-randomized clinical trials comprising 557 patients were included, 299 patients for levosimendan and 258 patients for control groups. The pooled prevalence of veno-arterial extracorporeal membrane oxygenation successful weaning was 61.4% (95% confidence interval 39.8-82.9%), and all-cause mortality was 36% (95% confidence interval 29.6-48.8%). There was a significant increase in veno-arterial extracorporeal membrane oxygenation successful weaning with levosimendan compared to the controls (risk ratio = 1.42 (95% confidence interval 1.12-1.8), p for effect = 0.004, I2 = 71%). A decrease risk of all-cause mortality in the levosimendan group was also observed, risk ratio = 0.62 (95% confidence interval 0.44-0.88), p for effect = 0.007, I2 = 36%. Conclusion: The use of levosimendan on adult patients with cardiogenic shock may facilitate the veno-arterial extracorporeal membrane oxygenation weaning and reduce all-cause mortality. Few articles of this topic are available, and prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of levosimendan in this setting.
Collapse
Affiliation(s)
- Lucrecia María Burgos
- Heart Failure, Pulmonary Hypertension and Transplant Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Leonardo Seoane
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Francisco Furmento
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Pablo Costabel
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Mirta Diez
- Heart Failure, Pulmonary Hypertension and Transplant Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Mariano Vrancic
- Cardiac Surgery Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Nadia Aissaoui
- Penn State Heart and Vascular Institute (HVI), Critical Care Unit, Penn State Health Milton S. Hershey Medical Center (HMC), The Pennsylvania State University, Paris, France
| | - Mariano Noel Benzadón
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Daniel Navia
- Cardiac Surgery Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| |
Collapse
|
127
|
Duerschmied D, Zotzmann V, Rieder M, Bemtgen X, Biever PM, Kaier K, Trummer G, Benk C, Busch HJ, Bode C, Wengenmayer T, Stachon P, von Zur Mühlen C, Staudacher DL. Myocardial infarction type 1 is frequent in refractory out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR). Sci Rep 2020; 10:8423. [PMID: 32440003 PMCID: PMC7242317 DOI: 10.1038/s41598-020-65498-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/05/2020] [Indexed: 01/02/2023] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is a last resort treatment option for refractory cardiac arrest performed in specialized centers. Following consensus recommendations, ECPR is mostly offered to younger patients with witnessed collapse but without return of spontaneous circulation (ROSC). We report findings from a large single-center registry with 252 all-comers who received ECPR from 2011-2019. It took a median of 52 min to establish stable circulation by ECPR. Eighty-five percent of 112 patients with out-of-hospital cardiac arrest (OHCA) underwent coronary angiography, revealing myocardial infarction (MI) type 1 with atherothrombotic vessel obstruction in 70 patients (63% of all OHCA patients, 74% of OHCA patients undergoing coronary angiography). Sixty-six percent of 140 patients with intra-hospital cardiac arrest (IHCA) underwent coronary angiography, which showed MI type 1 in 77 patients (55% of all IHCA patients, 83% of IHCA patients undergoing coronary angiography). These results suggest that MI type 1 is a frequent finding and - most likely - cause of cardiac arrest (CA) in patients without ROSC, especially in OHCA. Hospital survival rates were 30% and 29% in patients with OHCA and IHCA, respectively. According to these findings, rapid coronary angiography may be advisable in patients with OHCA receiving ECPR without obvious non-cardiac cause of arrest, irrespective of electrocardiogram analysis. Almost every third patient treated with ECPR survived to hospital discharge, supporting previous data suggesting that ECPR may be beneficial in CA without ROSC. In conclusion, interventional cardiology is of paramount importance for ECPR programs.
Collapse
Affiliation(s)
- D Duerschmied
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany.
| | - V Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - M Rieder
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - X Bemtgen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - P M Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - K Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - G Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - C Benk
- Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - H J Busch
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - C Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - T Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - P Stachon
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - C von Zur Mühlen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - D L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| |
Collapse
|
128
|
Chieffo A, Stefanini GG, Price S, Barbato E, Tarantini G, Karam N, Moreno R, Buchanan GL, Gilard M, Halvorsen S, Huber K, James S, Neumann FJ, Möllmann H, Roffi M, Tavazzi G, Mauri Ferré J, Windecker S, Dudek D, Baumbach A. EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic. Eur Heart J 2020; 41:1839-1851. [PMID: 32405641 PMCID: PMC7239193 DOI: 10.1093/eurheartj/ehaa381] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/15/2020] [Accepted: 05/06/2020] [Indexed: 12/15/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to healthcare worldwide. The infection can be life threatening and require intensive care treatment. The transmission of the disease poses a risk to both patients and healthcare workers. The number of patients requiring hospital admission and intensive care may overwhelm health systems and negatively affect standard care for patients presenting with conditions needing emergency interventions. This position statements aims to assist cardiologists in the invasive management of acute coronary syndrome (ACS) patients in the context of the COVID-19 pandemic. To that end, we assembled a panel of interventional cardiologists and acute cardiac care specialists appointed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and from the Acute Cardiovascular Care Association (ACVC) and included the experience from the first and worst affected areas in Europe. Modified diagnostic and treatment algorithms are proposed to adapt evidence-based protocols for this unprecedented challenge. Various clinical scenarios, as well as management algorithms for patients with a diagnosed or suspected COVID-19 infection, presenting with ST- and non-ST-segment elevation ACS are described. In addition, we address the need for re-organization of ACS networks, with redistribution of hub and spoke hospitals, as well as for in-hospital reorganization of emergency rooms and cardiac units, with examples coming from multiple European countries. Furthermore, we provide a guidance to reorganization of catheterization laboratories and, importantly, measures for protection of healthcare providers involved with invasive procedures.
Collapse
Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | | | | | - Emanuele Barbato
- Department of Advanced Biomedical Sciences University Federico II, Naples, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department) and University of Paris, Paris, France
| | - Raul Moreno
- Cardiology Department, Hospital La Paz and IDIPAZ, Madrid, Spain
| | - Gill Louise Buchanan
- Department of Cardiology, North Cumbria Integrated Care NHS Foundation Trust, Cumbria, UK
| | - Martine Gilard
- Service de Cardiologie, Brest University Hospital, Brest, France
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical School, Vienna, Austria
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Franz-Josef Neumann
- Division of Cardiology and Angiology II University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Helge Möllmann
- Department of Cardiology St.-Johannes-Hospital Klinik für Innere Medizin I, Dortmund, Germany
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Guido Tavazzi
- Department of clinical-surgical, diagnostic and pediatric sciences, Unit of anaesthesia and intensive care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | | | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland and Maria Cecilia Hospital GVM, Cotignola, Ravenna, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, Barts Heart Centre, London, UK and Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
129
|
Dennis M, Lal S, Forrest P, Nichol A, Lamhaut L, Totaro RJ, Burns B, Sandroni C. In-Depth Extracorporeal Cardiopulmonary Resuscitation in Adult Out-of-Hospital Cardiac Arrest. J Am Heart Assoc 2020; 9:e016521. [PMID: 32375010 PMCID: PMC7660839 DOI: 10.1161/jaha.120.016521] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of extracorporeal cardiopulmonary resuscitation (E‐CPR) for the treatment of patients with out‐of‐hospital cardiac arrest who do not respond to conventional cardiopulmonary resuscitation CPR) has increased significantly in the past 10 years, in response to case reports and observational studies reporting encouraging results. However, no randomized controlled trials comparing E‐CPR with conventional CPR have been published to date. The evidence from systematic reviews of the available observational studies is conflicting. The inclusion criteria for published E‐CPR studies are variable, but most commonly include witnessed arrest, immediate bystander CPR, an initial shockable rhythm, and an estimated time from CPR start to establishment of E‐CPR (low‐flow time) of <60 minutes. A shorter low‐flow time has been consistently associated with improved survival. In an effort to reduce low‐flow times, commencement of E‐CPR in the prehospital setting has been reported and is currently under investigation. The provision of an E‐CPR service, whether hospital based or prehospital, carries considerable cost and technical challenges. Despite increased adoption, many questions remain as to which patients will derive the most benefit from E‐CPR, when and where to implement E‐CPR, optimal post‐arrest E‐CPR care, and whether this complex invasive intervention is cost‐effective. Results of ongoing trials are awaited to determine whether E‐CPR improves survival when compared with conventional CPR.
Collapse
Affiliation(s)
- Mark Dennis
- Sydney Medical SchoolUniversity of SydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Sean Lal
- Sydney Medical SchoolUniversity of SydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Paul Forrest
- Sydney Medical SchoolUniversity of SydneyAustralia
- Department of AnaesthesiaRoyal Prince Alfred HospitalSydneyAustralia
| | - Alistair Nichol
- University College Dublin‐Clinical Research CentreSt Vincent’s University HospitalDublinIreland
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneAustralia
| | - Lionel Lamhaut
- INSERM U970 Team 4 “Sudden Death Expertise Center”ParisFrance
- Paris Descartes UniversityParisFrance
- SAMU de Paris‐DAR Necker University Hospital‐Assistance Public Hopitaux de ParisParisFrance
| | - Richard J. Totaro
- Department of Intensive CareRoyal Prince Alfred HospitalSydneyAustralia
| | - Brian Burns
- Greater Sydney Area Helicopter Emergency Medical ServiceNew South Wales, Ambulance Service???Australia
| | - Claudio Sandroni
- Istituto Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore – Policlinico Universitario Agostino Gemelli – IRCCSRomeItaly
| |
Collapse
|
130
|
[Ultrasound in the management of the critically ill patient with SARS-CoV-2 infection (COVID-19): narrative review]. Med Intensiva 2020; 44:551-565. [PMID: 32527471 PMCID: PMC7198178 DOI: 10.1016/j.medin.2020.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
La infección por SARS-CoV-2 (COVID-19) se caracteriza por producir en las formas graves, un cuadro de insuficiencia respiratoria que puede evolucionar hacia neumonía y síndrome de distrés respiratorio agudo (SDRA), presentar complicaciones como fenómenos trombóticos y disfunción cardiaca, lo que motiva el ingreso en la Unidad de Cuidados Intensivos (UCI). La ecografía, convertida en una herramienta de uso habitual en la UCI, puede ser muy útil durante la pandemia por COVID-19 ya que la información obtenida por el clínico puede ser interpretada e integrada en la valoración global durante la exploración del paciente. Este documento describe algunas de sus aplicaciones, adaptadas al paciente crítico con COVID-19, con el objetivo de proporcionar una guía a los médicos responsables. Alguna de sus aplicaciones desde el ingreso en la UCI incluyen: confirmar la correcta posición del tubo endotraqueal, facilitar la inserción segura de las vías e identificar complicaciones y fenómenos trombóticos. Además, la ecografía pleuropulmonar puede ser una alternativa diagnóstica válida que permite evaluar el grado de afectación pulmonar, mediante el análisis de patrones ecográficos específicos, la identificación de derrame pleural y barotrauma. La ecocardiografía proporciona información acerca de la afectación cardiaca, detección del cor pulmonale y estados de shock.
Collapse
|
131
|
Ramanathan K, Antognini D, Combes A, Paden M, Zakhary B, Ogino M, MacLaren G, Brodie D, Shekar K. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. THE LANCET. RESPIRATORY MEDICINE 2020; 8:518-526. [PMID: 32203711 PMCID: PMC7102637 DOI: 10.1016/s2213-2600(20)30121-1] [Citation(s) in RCA: 351] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 02/27/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023]
Abstract
WHO interim guidelines recommend offering extracorporeal membrane oxygenation (ECMO) to eligible patients with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). The number of patients with COVID-19 infection who might develop severe ARDS that is refractory to maximal medical management and require this level of support is currently unknown. Available evidence from similar patient populations suggests that carefully selected patients with severe ARDS who do not benefit from conventional treatment might be successfully supported with venovenous ECMO. The need for ECMO is relatively low and its use is mostly restricted to specialised centres globally. Providing complex therapies such as ECMO during outbreaks of emerging infectious diseases has unique challenges. Careful planning, judicious resource allocation, and training of personnel to provide complex therapeutic interventions while adhering to strict infection control measures are all crucial components of an ECMO action plan. ECMO can be initiated in specialist centres, or patients can receive ECMO during transportation from a centre that is not specialised for this procedure to an expert ECMO centre. Ensuring that systems enable safe and coordinated movement of critically ill patients, staff, and equipment is important to improve ECMO access. ECMO preparedness for the COVID-19 pandemic is important in view of the high transmission rate of the virus and respiratory-related mortality.
Collapse
Affiliation(s)
- Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Hospital, National University of Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Bond University, Robina, QLD, Australia
| | | | - Alain Combes
- Institute of Cardiometabolism and Nutrition, University of Paris, Paris, France; Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Matthew Paden
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Mark Ogino
- Department of Paediatrics, Division of Neonatology, Nemours Alfred I duPont Hospital for Children, Wilmington, DE, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, National University of Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Paediatric Intensive Care Unit, The Royal Children's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Daniel Brodie
- Columbia University College of Physicians and Surgeons, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Kiran Shekar
- Bond University, Robina, QLD, Australia; University of Queensland, Brisbane, QLD, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia; Critical Care Research Group, Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support, Brisbane, QLD, Australia.
| |
Collapse
|
132
|
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
|
133
|
Abstract
Disclaimer: ECMO has, and will certainly continue, to play a role in the management of COVID-19 patients. It should be emphasized that this initial guidance is based on the current best evidence for ECMO use during this pandemic. Guidance documents addressing additional portions of ECMO care are currently being assembled for rapid publication and distribution to ECMO centers worldwide.
Collapse
|
134
|
Richards JB, Frakes M, Saia MS, Johnson R, Wilcox SR. Changes in Oxygen Saturation and Mean Arterial Pressure With Inhaled Epoprostenol in Transport. J Intensive Care Med 2020; 36:758-765. [PMID: 32266858 DOI: 10.1177/0885066620917658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Patients with hypoxemic respiratory failure have traditionally been considered one of the riskiest patient populations to transport, given the potential for desaturation with movement. We performed a retrospective cohort study to analyze our experience using inhaled epoprostenol in transport, with a primary objective of assessing change in the oxygen saturation throughout the transport. METHODS The transport records of patients with severe hypoxemic respiratory failure or right heart failure, transported on inhaled epoprostenol, were reviewed. The primary outcome was the change in SpO2 from the start of the inhaled epoprostenol transport to the time of handover of care at the receiving institution. The secondary outcome was the change in the mean arterial pressure (MAP). RESULTS Comparing the initial SpO2 to the final, there was no significant difference in oxygenation between time 0 and the transfer of care at the receiving hospital at 91% versus 93% (interquartile range [IQR] 86.0-93.5 vs 87.5-96.0, P = .49). Comparing the SpO2 for those who had inhaled epoprostenol started by the transport team showed a larger change at 86% compared to 93% (IQR: 83.0-91.0 vs 86.5-94.5, P = .04). There was no change in the median MAP from time 0 to the end of the transport (77 vs 75 mm Hg, IQR, 67.5-84.8 vs 68.5-85.8, P = .70). CONCLUSIONS In this study, patients with severe cardiopulmonary compromise transported on inhaled epoprostenol had no significant change in their median oxygen saturations, with the overall population increasing from 91% to 93%. When inhaled epoprostenol was initiated by the transport team, the improvement was clinically and statistically significant with an increase in SpO2 from 86% to 93%, with a final oxygen saturation comparable to those who were on the medication at the time of the team's arrival.
Collapse
Affiliation(s)
- Jeremy B Richards
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | - Susan R Wilcox
- Department of Emergency Medicine, Heart Center ICU, 2348Massachusetts General Hospital, MA, USA
| |
Collapse
|
135
|
Lüsebrink E, Stremmel C, Stark K, Joskowiak D, Czermak T, Born F, Kupka D, Scherer C, Orban M, Petzold T, von Samson-Himmelstjerna P, Kääb S, Hagl C, Massberg S, Peterss S, Orban M. Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:E992. [PMID: 32252267 PMCID: PMC7230450 DOI: 10.3390/jcm9040992] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
Collapse
Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Thomas Czermak
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick von Samson-Himmelstjerna
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Stefan Kääb
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| |
Collapse
|
136
|
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.
Collapse
Affiliation(s)
| | - Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
| |
Collapse
|
137
|
Chiumello D, Coppola S. Extracorporeal cardiopulmonary resuscitation in out of hospital cardiac arrest: Does exist the right patient? Resuscitation 2020; 148:271-272. [PMID: 31981711 DOI: 10.1016/j.resuscitation.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| |
Collapse
|
138
|
Karagiannidis C, Joost T, Strassmann S, Weber-Carstens S, Combes A, Windisch W, Brodie D. Safety and Efficacy of a Novel Pneumatically Driven Extracorporeal Membrane Oxygenation Device. Ann Thorac Surg 2020; 109:1684-1691. [PMID: 32119858 DOI: 10.1016/j.athoracsur.2020.01.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/03/2020] [Accepted: 01/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is rapidly becoming a mainstream technology for lung or heart/lung support. Current ECMO devices mostly consist of a power-driven centrifugal pump and a dedicated oxygenator. We studied the safety and efficacy of a novel, fully pneumatically driven ECMO device, which could be used in both venovenous or venoarterial mode in an animal model. METHODS Six healthy, awake sheep were treated with the Mobybox ECMO device (Hemovent, Aachen, Germany) over a 7-day period in a venovenous mode. Gas exchange, coagulation parameters, and safety were assessed. RESULTS Using a blood flow rate of 2 L/min and a low sweep gas flow rate of 0.3 L/min, the PCO2 ranged from 38 to 44 mm Hg pre oxygenator and dropped to 32 to 36 mm Hg post oxygenator, whereas the PaO2 post oxygenator increased to 600 mm Hg. Higher levels of sweep gas flow resulted in cessation of spontaneous breathing in some animals, consistent with high-efficiency carbon dioxide removal; thus, the sweep gas flow rate was maintained at a low level. Platelets dropped from 177 ± 53/μL to 107 ± 28/μL on day 2, while returning to baseline by day 7 (180 ± 51/μL). Plasma-free hemoglobin remained low (2-9 mg/dL), whereas fibrinogen slightly increased, and then remained stable throughout the period. Neither the pump nor the oxygenator showed any visible clotting after 7 days. CONCLUSIONS The pneumatically driven ECMO device provided excellent safety and physiologic efficacy in a 7-day sheep experiment without visible clotting, hemolysis, or sustained reductions in fibrinogen or platelets.
Collapse
Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS, Cologne, Germany; ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany.
| | | | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS, Cologne, Germany; ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Berlin, Germany; Humboldt Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique, Hopitaux de Paris, Paris, France
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS, Cologne, Germany; ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Daniel Brodie
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| |
Collapse
|
139
|
What's new in cardiogenic shock? Intensive Care Med 2020; 46:1016-1019. [PMID: 32103283 DOI: 10.1007/s00134-020-05973-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
|
140
|
Charlesworth M, Garcia M, Head L, Barker JM, Ashworth AD, Barnard JB, Feddy L, Venkateswaran RV. Venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock-A six-year service evaluation. Artif Organs 2020; 44:709-716. [PMID: 31970800 DOI: 10.1111/aor.13647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/03/2019] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA-ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial-ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra-aortic balloon counterpulsation on the intensive care unit. 30-day, hospital discharge, 1-year and 2-year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4-9 [1-35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA-ECMO. We suggest postoperative VA-ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.
Collapse
Affiliation(s)
- Michael Charlesworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Miguel Garcia
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Laura Head
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Julian M Barker
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alan D Ashworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - James B Barnard
- Department of Cardiothoracic Surgery and Transplantation, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lee Feddy
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rajamiyer V Venkateswaran
- Department of Cardiothoracic Surgery and Transplantation, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Department of Cardiovascular Science, University of Manchester, Manchester, UK
| |
Collapse
|
141
|
Ali JM, Vuylsteke A, Fowles JA, Pettit S, Salaunkey K, Bhagra S, Lewis C, Parameshwar J, Kydd A, Patvardhan C, Jones N, Rubino A, Abu-Omar Y, Sudarshan C, Tsui S, Catarino P, Jenkins DP, Berman M. Transfer of Patients With Cardiogenic Shock Using Veno-Arterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:374-382. [DOI: 10.1053/j.jvca.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/10/2019] [Accepted: 05/11/2019] [Indexed: 01/06/2023]
|
142
|
Vandenbriele C, Vanassche T, Price S. Why we need safer anticoagulant strategies for patients on short-term percutaneous mechanical circulatory support. Intensive Care Med 2020; 46:771-774. [PMID: 31974917 DOI: 10.1007/s00134-019-05897-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/06/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK.
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK
| |
Collapse
|
143
|
Shao J, Wang L, Wang H, Hou X. Predictors for unsuccessful weaning from venoarterial extracorporeal membrane oxygenation in patients undergoing coronary artery bypass grafting. Perfusion 2020; 35:598-607. [PMID: 31960735 DOI: 10.1177/0267659119900124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Studies reporting risk factors associated with unsuccessful weaning for coronary artery bypass grafting patients on venoarterial extracorporeal membrane oxygenation are scarce. This study was designed to identify factors associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation. Methods: Data from 166 coronary artery bypass grafting patients supported with venoarterial extracorporeal membrane oxygenation at the Beijing Anzhen Hospital between February 2004 and March 2017 were retrospectively analyzed. Multivariable logistic regression was performed using bootstrapping methodology to identify factors independently associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation. Results: A total of 106 patients (64%) could be weaned from venoarterial extracorporeal membrane oxygenation, and 74 patients (45%) were alive at hospital discharge. The 30-day and 60-day survival rates after ECMO weaning were 72% and 70%, respectively. Pre-existing hypertension (odds ratio, 2.54; 95% confidence interval, 1.16-5.56; p = 0.02), serum creatinine (+1 μmol/L; odds ratio, 1.008; 95% confidence interval, 1.003-1.013; p = 0.001), and serum lactate (+1 mmol/L; odds ratio, 1.17; 95% confidence interval, 1.08-1.26; p = 0.001) were independent risk factors associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation. Higher platelet count was protective (+1 × 109/L; odds ratio, 0.992; 95% confidence interval, 0.986-0.998; p = 0.011). The area under the receiver operating characteristic curve 0.81 (95% confidence interval, 0.75-0.88) for the logistic regression model was better than those for the survival after VA-ECMO score (p = 0.002), EuroSCORE (p < 0.001), and the prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by VA-ECMO scores (p = 0.02) in this population. The pRedicting mortality in patients undergoing venoarterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (0.76; 95% confidence interval, 0.68-0.83; p = 0.29) and sepsis-related organ failure assessment score (0.77; 95% confidence interval, 0.70-0.85; p = 0.46) exhibited good performances similar to the logistic regression model. Conclusion: Pre-existing hypertension, serum creatinine, serum lactate, and low platelet count were independent predictors for unsuccessful weaning from venoarterial extracorporeal membrane oxygenation in patients undergoing coronary artery bypass grafting.
Collapse
Affiliation(s)
- Juanjuan Shao
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
144
|
MacLaren G, Masoumi A, Brodie D. ECPR for out-of-hospital cardiac arrest: more evidence is needed. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:7. [PMID: 31910905 PMCID: PMC6947922 DOI: 10.1186/s13054-019-2722-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/27/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, 5 Lower Kent Ridge Rd., Singapore, 119074, Singapore. .,Paediatric Intensive Care Unit, Department of Paediatrics, The Royal Children's Hospital, University of Melbourne, Flemington Rd., Parkville, VIC, 3052, Australia.
| | - Amirali Masoumi
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA
| | - Daniel Brodie
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA
| |
Collapse
|
145
|
Chonde M, Escajeda J, Elmer J, Callaway CW, Guyette FX, Boujoukos A, Sappington PL, Smith AJ, Schmidhofer M, Sciortino C, Kormos RL. Challenges in the development and implementation of a healthcare system based extracorporeal cardiopulmonary resuscitation (ECPR) program for the treatment of out of hospital cardiac arrest. Resuscitation 2019; 148:259-265. [PMID: 31887368 DOI: 10.1016/j.resuscitation.2019.12.015] [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] [Received: 04/11/2019] [Revised: 12/12/2019] [Accepted: 12/17/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Many institutions are interested in developing their own ECPR program. However, there may be challenges in logistics and implementation. AIMS The aim of our protocol was to demonstrate that an ECPR team was feasible within our healthcare system and that the identification of UPMC Presbyterian as a receiving center allowed for successful treatment within 30 min from EMS dispatch. METHODS We developed out of hospital cardiac arrest (OHCA) ECPR protocols for Emergency Medical Services (EMS), EMS communications, and our in-hospital ECPR team. Inclusion criteria indentified patients with a potentially reversible arrest etiology and high probability of recoverable brain injury using a simple checklist: witnessed collapse, layperson CPR, initial shockable rhythm, and age 18-60 years. We trained local EMS crews to screen patients and reviewed the criteria with a Medic Command Physician prior to transport to our hospital. RESULTS From October 2015 to March 31st 2018, EMS treated 1165 EMS OHCA cases, transported 664 (57%) to a local hospital, and transported 120 (10%) to our institution. Of these, five (4.1%) patients underwent ECPR. Among excluded cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. For ECPR cases, median pre-hospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) received mechanical CPR. Interval from arrest to arrival on scene was 5 [IQR 4-6] min and interval from radio call to activation of ECPR was 13 [IQR 7-21] min. Interval from EMS dispatch to departure from scene was 20 [IQR 19-21] min. Time from EMS dispatch to initiation of ECPR was 63 [IQR 59-69] min. CONCLUSIONS ECPR is an infrequent occurrence in EMS practice. Most apparently eligible patients did not get ECPR, highlighting the need for ongoing programmatic development, provider education, and qualitative work exploring barriers to implementation.
Collapse
Affiliation(s)
- Meshe Chonde
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States.
| | - Jeremiah Escajeda
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Jonathan Elmer
- University of Pittsburgh, Department of Emergency Medicine, United States; University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Clifton W Callaway
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Frank X Guyette
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Arthur Boujoukos
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Penny L Sappington
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Anson J Smith
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | - Mark Schmidhofer
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | | | - Robert L Kormos
- University of Pittsburgh, Department of Cardiothoracic Surgery, United States
| |
Collapse
|
146
|
Extracorporeal Life Support in Adult Patients: A Global Perspective of the Last Decade. Dimens Crit Care Nurs 2019; 38:123-130. [PMID: 30946118 DOI: 10.1097/dcc.0000000000000351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal life support (ECLS) is an external medical device to treat critically ill patients with cardiovascular and respiratory failure. In a nutshell, ECLS is only a "bridging" mechanism that provides life support while the heart and/or the lungs is recovering either by therapeutic medical interventions, transplantation, or spontaneously. Extracorporeal life support has been developed since 1950s, and many studies were conducted to improve ECLS techniques, but unfortunately, the survival rate was not improved. Because of Dr Bartlett's success in using ECLS to treat neonates with severe respiratory distress in 1975, ECLS is made as a standard lifesaving therapy for neonates with severe respiratory distress. However, its use for adult patients remains debatable. The objectives of this study are to outline and provide a general overview of the use of ECLS especially for adult patients for the past 10 years and to elaborate on the challenges encountered by each stakeholder involved in ECLS. The data used for this study were extracted from the ELSO Registry Report of January 2018. Results of this study revealed that the number of ECLS centers and the use of ECLS are increasing over the year for the past decade. There was also a shift of the patient's age category from neonatal to adult patients. However, the survival rates for adult patients are relatively low especially for cardiac and extracorporeal cardiopulmonary resuscitation cases. To date, the complications are still the major challenge of ECLS. Other challenges encountered by the stakeholders in ECLS are the limited amount of well-trained and experienced ECLS teams and centers, the limited government expenditure on health, and the lack of improvement and development of ECLS techniques and devices. Further studies are needed to evaluate the value of ECLS for adult patients.
Collapse
|
147
|
Michels G, Wengenmayer T, Hagl C, Dohmen C, Böttiger BW, Bauersachs J, Markewitz A, Bauer A, Gräsner JT, Pfister R, Ghanem A, Busch HJ, Kreimeier U, Beckmann A, Fischer M, Kill C, Janssens U, Kluge S, Born F, Hoffmeister HM, Preusch M, Boeken U, Riessen R, Thiele H. [Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]. Anaesthesist 2019; 67:607-616. [PMID: 30014276 DOI: 10.1007/s00101-018-0473-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.
Collapse
Affiliation(s)
- G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - T Wengenmayer
- Klinik für Kardiologie und Angiologie I, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Medizinische Fakultät der Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - C Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Ludwig-Maximilians-Universität, München, Deutschland
| | - C Dohmen
- LVR-Klinik Bonn, Bonn, Deutschland
| | - B W Böttiger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | - J Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | | | - A Bauer
- MediClin Herzzentrum Coswig, Coswig, Deutschland
| | - J-T Gräsner
- Institut für Rettungs- und Notfallmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - R Pfister
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - A Ghanem
- Abteilung Kardiologie, II. Medizinische Klinik, Asklepios Klinik St. Georg, Hamburg, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Medizinische Fakultät der Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - U Kreimeier
- Klinik für Anästhesiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität, München, Deutschland
| | - A Beckmann
- Herzzentrum Duisburg, Klinik für Herz- und Gefäßchirurgie, Evangelisches Krankenhaus Niederrhein, Duisburg, Deutschland
| | - M Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, ALB FILS KLINIKEN GmbH, Klinik am Eichert, Göppingen, Deutschland
| | - C Kill
- Zentrum für Notfallmedizin, Universitätsmedizin Essen, Essen, Deutschland
| | - U Janssens
- Klinik für Innere Medizin und Intensivmedizin, St.-Antonius-Hospital, Eschweiler, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - F Born
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Ludwig-Maximilians-Universität, München, Deutschland
| | - H M Hoffmeister
- Klinik für Kardiologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen gGmbH, Solingen, Deutschland
| | - M Preusch
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - U Boeken
- Klinik für Kardiovaskuläre Chirurgie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - R Riessen
- Department für Innere Medizin, Internistische Intensivstation, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - H Thiele
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universitätsklinik, Leipzig, Deutschland
| |
Collapse
|
148
|
Leurent G, Auffret V, Pichard C, Laine M, Bonello L. Is there still a role for the intra-aortic balloon pump in the management of cardiogenic shock following acute coronary syndrome? Arch Cardiovasc Dis 2019; 112:792-798. [DOI: 10.1016/j.acvd.2019.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022]
|
149
|
ECLS-associated infections in adults: what we know and what we don't yet know. Intensive Care Med 2019; 46:182-191. [PMID: 31768569 PMCID: PMC7222121 DOI: 10.1007/s00134-019-05847-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/30/2019] [Indexed: 01/17/2023]
Abstract
Extracorporeal life support (ECLS) is increasingly used in the management of patients with severe cardiopulmonary disease. Infections are frequently the etiologies underlying the respiratory, and occasionally cardiac, failure that necessitates ECLS. Just as importantly, infections are among the most commonly reported adverse events during ECLS. Infections in this setting may be the sequelae of prolonged critical illness or of underlying immune dysregulation; they may be hospital-acquired infections, and they may or may not be attributable to the presence of ECLS itself, the latter being an aspect that can be difficult to determine. Current registry data and evidence from the literature offer some insights, but also leave open many questions regarding the nature and significance of infections reported both before and during ECLS, including the question of any causal link between ECLS and the development of infections. An ongoing lack of consistency in the identification, diagnosis, management, and prevention of infections during ECLS is limiting our ability to interpret literature data and thus highlighting the need for more rigorous investigation and standardization of definitions. This review aims to characterize the current understanding of infections associated with the use of ECLS, taking into account data from the updated Extracorporeal Life Support Organization Registry, which provides important context for understanding the epidemiology and outcomes of these patients.
Collapse
|
150
|
Vieira J, Frakes M, Cohen J, Wilcox S. Extracorporeal Membrane Oxygenation in Transport Part 1: Extracorporeal Membrane Oxygenation Configurations and Physiology. Air Med J 2019; 39:56-63. [PMID: 32044071 DOI: 10.1016/j.amj.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 12/30/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO), a term used to describe oxygenation that occurs outside of the body, is an increasingly common means of supporting the most critically ill patients. Because of the invasiveness and high probability of serious complications during ECMO, ECMO is typically indicated only when there is a high likelihood of death with conventional treatment. With continued improvements in technology and increasing clinical experience, transport clinicians are increasingly likely to be called on to transport patients on ECMO. ECMO can be initiated in 2 distinct forms, venovenous or venoarterial, and can primarily support the respiratory system or the cardiac and respiratory systems concurrently. This review will cover the basic physiology and components of ECMO as well as the preparation for ECMO transport for adults.
Collapse
Affiliation(s)
| | | | - Jason Cohen
- Boston MedFlight, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Susan Wilcox
- Boston MedFlight, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|