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Patangi SO, Shetty RS, Shanmugasundaram B, Kasturi S, Raheja S. Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock' - A review with an Indian perspective. Indian J Thorac Cardiovasc Surg 2021; 37:275-288. [PMID: 33191992 PMCID: PMC7647874 DOI: 10.1007/s12055-020-01051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/14/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve 'milieu intérieur'. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.
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Affiliation(s)
- Sanjay Orathi Patangi
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Riyan Sukumar Shetty
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Balasubramanian Shanmugasundaram
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Srikanth Kasturi
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Shivangi Raheja
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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Efficacy of Prophylactic Antibiotics during Extracorporeal Membrane Oxygenation: A Nationwide Cohort Study. Ann Am Thorac Soc 2021; 18:1861-1867. [PMID: 33765406 DOI: 10.1513/annalsats.202008-974oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) is widely used worldwide, and many hospitals consider using antibiotics to prevent nosocomial infection in ECMO patients. However, the efficacy of antimicrobial prophylaxis for patients receiving ECMO remains unclear. OBJECTIVE This study aimed to evaluate the efficacy of prophylactic antibiotics for ECMO patients. METHODS This retrospective cohort study was performed using data recorded in the Japanese Diagnosis Procedure Combination database from July 1, 2010, to March 31, 2017. We compared in-hospital mortality, nosocomial pneumonia, acute kidney injury, and diarrhea between patients receiving prophylactic antibiotics (prophylaxis group) and those not receiving antibiotics (control group) using propensity score matching, multivariable logistic regression models fitted using generalized estimating equation, stabilized inverse probability of treatment weighting, and instrumental variable analysis. RESULTS We identified 9615 eligible patients and classified them into the prophylaxis (n = 5552) and control (n = 4063) groups. In the propensity score-matched analysis, 3650 pairs were generated. Significant differences between the prophylaxis group and the control group were detected in in-hospital mortality (56.4% vs 59.8%, risk difference: -3.7%, 95% confidence interval [CI]: -6.0 to -1.3) and nosocomial pneumonia (12.9% vs. 15.3%, risk difference: -2.4%, 95% CI: -4.3 to -0.6). In the multivariable logistic regression models fitted using generalized estimating equation, stabilized inverse probability of treatment weighting, and instrumental variable analysis, the point estimates a suggested similar direction to that found in the propensity score analysis. The proportions of patients with acute kidney injury or diarrhea did not significantly increase with the use of prophylactic antibiotics. CONCLUSION Using prophylactic antibiotics during ECMO was associated with reduced in-hospital mortality and lower proportions of patients with nosocomial pneumonia. Future prospective studies are needed to validate these results.
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104
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Abstract
Successful weaning from extracorporeal membrane oxygenation (ECMO) does not necessarily imply patient survival. We retrospectively analyzed 441 patients with acute respiratory failure from 16 hospitals in South Korea who underwent ECMO from January 2012 to December 2015. We evaluated the clinical factors associated with mortality after successful weaning from ECMO. Of all 441 patients, 245 (55.6%) were successfully weaned from ECMO. The majority of patients were initially supported with veno-venous ECMO (86.9%). Among those, 182 patients (41.3%) were discharged from hospital. Only 165 (37.4%) were alive after 6 months. Most cases of death occurred within the first month after weaning from ECMO (65%), and the most frequent reason for death was sepsis (76.2%). In the multivariate Cox regression analysis, patient age (per 10 years) (hazard ratio [HR] = 1.34, 95% CI = 1.12-1.61; p = 0.001), sequential organ failure assessment score (HR = 1.07, 95% CI = 1.02-1.13; p = 0.010), steroid (HR = 2.38, 95% CI = 1.27-4.45; p = 0.007), interstitial lung disease (HR = 1.20, 95% CI = 1.05-1.36; p = 0.006), and ECMO duration (per day) (HR = 1.02, 95% CI = 1.01-1.04; p < 0.001) were associated with the in-hospital mortality after weaning from ECMO. Furthermore, age (per 10 years) (HR = 1.45, 95% CI = 1.24-1.71; p < 0.001), steroid (HR = 2.19, 95% CI = 1.27-3.78; p = 0.005), and interstitial lung disease (HR = 1.16, 95% CI = 1.02-1.31; p = 0.021) were significantly associated with 6 month mortality. The prognosis after weaning from respiratory ECMO might be related to baseline conditions affecting the reversibility of the primary lung disease and to acquired infections.
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105
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Solla-Buceta M, González-Vílchez F, Almenar-Bonet L, Lambert-Rodríguez JL, Segovia-Cubero J, González-Costello J, Delgado JF, Pérez-Villa F, Crespo-Leiro MG, Rangel-Sousa D, Martínez-Sellés M, Rábago-Juan-Aracil G, De-la-Fuente-Galán L, Blasco-Peiró T, Hervás-Sotomayor D, Garrido-Bravo IP, Mirabet-Pérez S, Muñiz J, Barge-Caballero E. Infectious complications associated with short-term mechanical circulatory support in urgent heart transplant candidates. ACTA ACUST UNITED AC 2021; 75:141-149. [PMID: 33648882 DOI: 10.1016/j.rec.2020.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES Short-term mechanical circulatory support is frequently used as a bridge to heart transplant in Spain. The epidemiology and prognostic impact of infectious complications in these patients are unknown. METHODS Systematic description of the epidemiology of infectious complications and analysis of their prognostic impact in a multicenter, retrospective registry of patients treated with short-term mechanical devices as a bridge to urgent heart transplant from 2010 to 2015 in 16 Spanish hospitals. RESULTS We studied 249 patients, of which 87 (34.9%) had a total of 102 infections. The most frequent site was the respiratory tract (n=47; 46.1%). Microbiological confirmation was obtained in 78 (76.5%) episodes, with a total of 100 causative agents, showing a predominance of gram-negative bacteria (n=58, 58%). Compared with patients without infection, those with infectious complications showed higher mortality during the support period (25.3% vs 12.3%, P=.009) and a lower probability of receiving a transplant (73.6% vs 85.2%, P=.025). In-hospital posttransplant mortality was similar in the 2 groups (with infection: 28.3%; without infection: 23.4%; P=.471). CONCLUSIONS Patients supported with temporary devices as a bridge to heart transplant are exposed to a high risk of infectious complications, which are associated with higher mortality during the organ waiting period.
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Affiliation(s)
- Miguel Solla-Buceta
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | | | - Luis Almenar-Bonet
- Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Universitat de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - José Luis Lambert-Rodríguez
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Asturias, Spain
| | - Javier Segovia-Cubero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - José González-Costello
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan F Delgado
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Fundación de Investigación I+12, Madrid, Spain; Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Félix Pérez-Villa
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínic i Provincial, Barcelona, Spain
| | - María G Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | - Diego Rangel-Sousa
- Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | | | | | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Iris P Garrido-Bravo
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Sonia Mirabet-Pérez
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Ciencias de la Salud, Universidade da Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | - Eduardo Barge-Caballero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
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106
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Zotzmann V, Wengenmayer T, Lang CN, Staudacher DL, Mueller-Peltzer K, Bamberg F, Marks R, Bode C, Wäsch R. Case Report: Refusal of an Veno-Arterial Extracorporeal Membrane Oxygenation Due to Malignant Disease? - An Extremely Rare Form of Cardiac Involvement in Acute Myeloid Leukemia. Front Med (Lausanne) 2021; 8:584507. [PMID: 33708776 PMCID: PMC7940367 DOI: 10.3389/fmed.2021.584507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/04/2021] [Indexed: 11/20/2022] Open
Abstract
We report here on a 61-year-old patient with acute right heart failure of unclear etiology. Echocardiography revealed a myocardial mass infiltrating the heart, though, we assumed a cardiac lymphoma. A VA-ECMO was implanted as bridging for diagnosis and therapy. Our patient received chemotherapy, under which the tumor (of unknown etiology at this point) reached a partial remission. Nine months after first admission the patient developed acute myeloid leukemia with DNMT3a and TET2 mutations. Retrospective analysis of the cardiac biopsy revealed the identical mutations and matched with the diagnosis of an extremely rare primary extramedullary manifestation of an AML (myelosarcoma). The patient received induction-chemotherapy and was planned for consolidating allogeneic stem cell transplantation. From this case, we conclude that an extracorporeal therapy should be discussed in selected patients even in case of an initially fatal appearing prognosis. In selected cases, extracorporeal support can generate enough time for diagnosis and therapy. However, transparent planning, including discussion of best supportive care strategies involving the patient's family are indispensable requirements for starting ECMO in such patients.
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Affiliation(s)
- Viviane Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Corinna N Lang
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Katharina Mueller-Peltzer
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Reinhard Marks
- Department of Medicine I (Hematology, Oncology, and Stem-Cell Transplantation), Faculty of Medicine, Medical Center, Freiburg im Breisgau, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology, and Stem-Cell Transplantation), Faculty of Medicine, Medical Center, Freiburg im Breisgau, Germany
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107
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Frerou A, Lesouhaitier M, Gregoire M, Uhel F, Gacouin A, Reizine F, Moreau C, Loirat A, Maamar A, Nesseler N, Anselmi A, Flecher E, Verhoye JP, Le Tulzo Y, Cogné M, Roussel M, Tarte K, Tadié JM. Venoarterial extracorporeal membrane oxygenation induces early immune alterations. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:9. [PMID: 33407728 PMCID: PMC7788860 DOI: 10.1186/s13054-020-03444-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/16/2020] [Indexed: 02/08/2023]
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides heart mechanical support in critically ill patients with cardiogenic shock. Despite important progresses in the management of patients under VA-ECMO, acquired infections remain extremely frequent and increase mortality rate. Since immune dysfunctions have been described in both critically ill patients and after surgery with cardiopulmonary bypass, VA-ECMO initiation may be responsible for immune alterations that may expose patients to nosocomial infections (NI). Therefore, in this prospective study, we aimed to study immune alterations induced within the first days by VA-ECMO initiation. Methods We studied immune alterations induced by VA-ECMO initiation using cytometry analysis to characterize immune cell changes and enzyme-linked immunosorbent assay (ELISA) to explore plasma cytokine levels. To analyze specific changes induced by VA-ECMO initiation, nine patients under VA-ECMO (VA-ECMO patients) were compared to nine patients with cardiogenic shock (control patients). Results Baseline immune parameters were similar between the two groups. VA-ECMO was associated with a significant increase in circulating immature neutrophils with a significant decrease in C5a receptor expression. Furthermore, we found that VA-ECMO initiation was followed by lymphocyte dysfunction along with myeloid-derived suppressor cells (MDSC) expansion. ELISA analysis revealed that VA-ECMO initiation was followed by an increase in pro-inflammatory cytokines such as IL-6, IL-8 and TNF-α along with IL-10, a highly immunosuppressive cytokine. Conclusion VA-ECMO is associated with early immune changes that may be responsible for innate and adaptive immune alterations that could confer an increased risk of infection.
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Affiliation(s)
- Aurélien Frerou
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | - Mathieu Lesouhaitier
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | - Murielle Gregoire
- INSERM, EFS Bretagne, UMR U1236, Université de Rennes 1, 35000, Rennes, France.,Pôle Biologie, CHU Rennes, 35033, Rennes, France
| | - Fabrice Uhel
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | - Arnaud Gacouin
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | - Florian Reizine
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | | | - Aurélie Loirat
- Service de Cardiologie et maladies vasculaires, CHU de Rennes, 35033, Rennes, France
| | - Adel Maamar
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | | | - Amedeo Anselmi
- Chirurgie Cardio-Thoracique Et Vasculaire, CHU Rennes, 35033, Rennes, France
| | - Erwan Flecher
- Chirurgie Cardio-Thoracique Et Vasculaire, CHU Rennes, 35033, Rennes, France
| | | | - Yves Le Tulzo
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France
| | - Michel Cogné
- INSERM, EFS Bretagne, UMR U1236, Université de Rennes 1, 35000, Rennes, France.,Pôle Biologie, CHU Rennes, 35033, Rennes, France
| | - Mikael Roussel
- INSERM, EFS Bretagne, UMR U1236, Université de Rennes 1, 35000, Rennes, France.,Pôle Biologie, CHU Rennes, 35033, Rennes, France
| | - Karin Tarte
- INSERM, EFS Bretagne, UMR U1236, Université de Rennes 1, 35000, Rennes, France.,Pôle Biologie, CHU Rennes, 35033, Rennes, France
| | - Jean-Marc Tadié
- Maladies Infectieuses Et Réanimation Médicale, CHU Rennes, 35033, Rennes, France. .,INSERM, EFS Bretagne, UMR U1236, Université de Rennes 1, 35000, Rennes, France. .,Pôle Biologie, CHU Rennes, 35033, Rennes, France.
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108
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Yun JH, Hong SB, Jung SH, Kang PJ, Sung H, Kim MN, Kim SH, Lee SO, Choi SH, Woo JH, Kim YS, Chong YP. Epidemiology and Clinical Characteristics of Bloodstream Infection in Patients Under Extracorporeal Membranous Oxygenation. J Intensive Care Med 2020; 36:1053-1060. [PMID: 33375874 DOI: 10.1177/0885066620985538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bloodstream infection (BSI) is an important complication of extracorporeal membranous oxygenation (ECMO) and a major cause of mortality. This study evaluated the epidemiological and clinical characteristics of BSI that occur during ECMO application according to microbial etiology. METHODS Adult patients who underwent ECMO from January 2009 to December 2016 were retrospectively analyzed for BSI episodes at a 2,700-bed, tertiary center. Epidemiological and clinical characteristics and outcomes of BSI were evaluated and were compared for etiologic groups (gram-positive cocci, gram-negative rods, and fungi groups). Risk factors for 14-day mortality were analyzed. RESULTS A total of 1,100 patients underwent ECMO during the study period, and 65 BSI episodes occurred in 61 patients. The BSI incidence was 8.3 episodes/1,000 ECMO days, which significantly decreased over time (P = 0.03), primarily in gram-positive cocci BSI. Gram-positive cocci, gram-negative rods, and fungi accounted for 38%, 40%, and 22% of the 73 blood isolates, respectively. Baseline characteristics were comparable between groups. Catheter-related infection (CRI) and pneumonia were the most common sources of BSI; 52% of gram-positive cocci BSIs and 79% of fungi BSIs were caused by CRI, and 75% of gram-negative BSIs by pneumonia. Patients with gram-negative rods BSI died more frequently and earlier than those with other BSIs. Independent risk factors for 14-day mortality were older age and gram-negative rods BSI. CONCLUSIONS The decreased BSI incidence during ECMO was mainly because of the decrease of gram-positive cocci BSI. The high early mortality of gram-negative rods BSI makes prevention and adequate treatment necessary.
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Affiliation(s)
- Ji Hyun Yun
- Department of Infectious Diseases, 119754Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea.,Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Pil Je Kang
- Department of Thoracic and Cardiovascular Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang-Soo Kim
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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109
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A Retrospective Study of Infection in Patients Requiring Extracorporeal Membrane Oxygenation Support. Ann Thorac Surg 2020; 112:1168-1175. [PMID: 33359722 DOI: 10.1016/j.athoracsur.2020.12.012] [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] [Received: 01/29/2020] [Revised: 12/02/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) in critically ill patients are a serious public health problem. Extracorporeal membrane oxygenation (ECMO) has been used increasingly for patients with severe cardiac or respiratory failure, but it may increase HAI risk. The goal of our study was to characterize HAIs in ECMO patients at an ECMO referral center. METHODS This institutional review board-approved study identified all consecutive adult ECMO patients admitted to the cardiac surgery intensive care unit (CSICU) between January 1, 2015, and December 31, 2017. Demographic data, diagnosis, ECMO cannulation technique, and survival were collected. Urinary tract infection, pneumonia, and bacteremia incidence during ECMO and within 3 months of decannulation were collected. Outcomes of patients with HAIs were compared with noninfected patients, the CSICU infection incidence, and overall Extracorporeal Life Support Organization survival data. RESULTS There were 288 ECMO patients and 3396 CSICU admissions during this period. Survival was 72.3% for venoarterial ECMO, 85.3% for venovenous ECMO, and 57.1% for multimodality or veno-arteriovenous ECMO, with discharge survival of 60.2%, 72.0%, and 28.6%, respectively. Bacteremia incidence while cannulated was 6.8% for venoarterial ECMO and 9.3% for venovenous ECMO. Bacteremia occurred in 22 of 288 (7.6%) ECMO patients, compared with 48 of 3109 (1.5%) in non-ECMO CSICU patients, which was statistically significant (P < .002). Bacteremia and pneumonia were associated with decreased VA-ECMO survival, with prolonged overall requirements for ECMO support. CONCLUSIONS Nosocomial ECMO infections are significantly higher than in other CSICU patients. Infection risk remains significant even after decannulation. Infection is associated with increased mortality and longer duration of ECMO support. Further efforts are needed to determine HAI reduction strategies in this high-risk patient population.
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110
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Ko RE, Huh K, Kim DH, Na SJ, Chung CR, Cho YH, Jeon K, Suh GY, Yang JH. Nosocomial infections in in-hospital cardiac arrest patients who undergo extracorporeal cardiopulmonary resuscitation. PLoS One 2020; 15:e0243838. [PMID: 33362276 PMCID: PMC7757900 DOI: 10.1371/journal.pone.0243838] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/29/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known of nosocomial infections (NI) in patients who suffer from in-hospital cardiac arrest who undergoing extracorporeal cardiopulmonary resuscitation. This study aimed to investigate clinical pictures of NI, and the association of NIs with clinical outcomes in in-hospital cardiac arrest patients who undergoing extracorporeal cardiopulmonary resuscitation. METHODS To evaluate the incidence and clinical characteristics of NI in patients who undergoing extracorporeal cardiopulmonary resuscitation, a retrospective cohort study was conducted in a single tertiary referral center between January 2010 and December 2018. We included adult patients who undergoing extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest and excluded patients who were out-of-hospital cardiac arrest or failed ECMO implantation. Clinical characteristics and outcomes were compared between NI and Non-NI patients, or multidrug-resistant (MDR) and non-MDR. The independent risk factors associated with NIs were also analyzed using multivariable logistic regression model. RESULTS Thirty-five (23.3%) patients developed a NI. These cases included 21 patients with a gram negative (G-) infection, 12 patients with a gram positive (G+) bacterial infection, and two patients with fungal infection. Pneumonia was the most common type of NIs, followed by catheter-related infection. The in-hospital mortality and neurologic outcomes at discharge were not different between the NI and non-NI groups. Multidrug-resistant (MDR) pathogens were detected in 10 cases (28.6%). The MDR NI patients had a higher ICU mortality than did those with non-MDR NI (80% vs. 32%, p = 0.028). Following multivariable adjustment, body mass index (adjusted OR 0.87, 95% CI, 0.77-0.97, p = 0.016) and cardiopulmonary resuscitation to pump on time (adjusted OR 1.04, 95% CI, 1.01-1.06, p = 0.001) were independent predictors of NI development. CONCLUSIONS In patients who received extracorporeal cardiopulmonary resuscitation, NIs were not associated with an increase in in-hospital mortality. However, NIs with MDR organisms do increase the risk of in-hospital mortality. Lower body mass index and longer low flow time were significant predictors of NI development.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Abstract
Pulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.
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112
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Morimura H, Tabata M. Delayed surgery after mechanical circulatory support for ventricular septal rupture with cardiogenic shock. Interact Cardiovasc Thorac Surg 2020; 31:868-873. [DOI: 10.1093/icvts/ivaa185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/03/2020] [Accepted: 07/26/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The effectiveness of delayed surgery for ventricular septal rupture (VSR) following myocardial infarction (MI) in patients with cardiogenic shock remains unknown. We aimed to investigate the outcomes of delayed surgery following mechanical circulatory support for patients in cardiogenic shock after VSR.
METHODS
We reviewed 8 patients with post-MI VSR and cardiogenic shock who underwent delayed surgery at our institution between July 2015 and November 2017. Surgery was delayed until haemodynamic stabilization and improved organ ischaemia were achieved by initiating intra-aortic balloon pumping with or without veno-arterial extracorporeal membrane oxygenation (ECMO). We investigated the operative mortality, morbidity and late survival.
RESULTS
All 8 patients had preoperative intra-aortic balloon pump support, and 5 had additional veno-arterial ECMO support. Emergency repair was successfully avoided in all cases. The median time from the onset of MI to operation was 7.1 (3.7–9.9) days, and that from the diagnosis of VSR to operation was 1.9 (1.3–2.3) days. The operative mortality was 12.5%, and complications related to mechanical circulatory support occurred in 1 case (12.5%). The 2-year survival rate was 62.5%.
CONCLUSIONS
A combination of preoperative mechanical circulatory support and delayed surgery may improve the outcomes of patients with post-MI VSR, which was complicated by cardiogenic shock. The key to a better surgical outcome may be delaying the surgery for improving end-organ perfusion. This requires further investigation, especially for determining the optimal duration of support.
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Affiliation(s)
- Hayato Morimura
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Urayasu, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Urayasu, Japan
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113
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Kim D, Na SJ, Cho YH, Chung CR, Jeon K, Suh GY, Park TK, Lee JM, Song YB, Hahn JY, Choi JH, Choi SH, Gwon HC, Ahn JH, Carriere KC, Yang JH. Predictors of Survival to Discharge After Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. Circ J 2020; 84:2205-2211. [PMID: 33041291 DOI: 10.1253/circj.cj-20-0550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study identified predictors of hospital mortality after successful weaning of patients with cardiogenic shock off venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support.Methods and Results:Adult patients who received peripheral VA ECMO from January 2012 to April 2017 were reviewed retrospectively. After excluding patients who died on ECMO support, predictors for survival to discharge were investigated in patients who were successfully weaned off ECMO. Of 191 patients successfully weaned off ECMO, 143 (74.9%) survived to discharge. The prevalence of a history of stroke and coronary artery disease, as well as ECMO-related complications, including newly developed stroke and sepsis, was a higher in patients who did not survive to discharge than in those who did. On the day of ECMO weaning, Sequential Organ Failure Assessment score and serum lactate were higher in patients who did not survive to discharge, although there was no significant difference in blood pressure and the use of vasoactive drugs between the 2 groups. On multivariable analysis, stroke and sepsis during ECMO support, a lower Glasgow Coma Scale and acute kidney injury requiring continuous renal replacement therapy after weaning were significant predictors for in-hospital mortality. CONCLUSIONS Complications that occurred during ECMO and the presence of extracardiac organ dysfunction after weaning were associated with in-hospital mortality in patients with cardiogenic shock who were successfully weaned off ECMO.
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Affiliation(s)
- Donghoon Kim
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Soo Jin Na
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Gee Young Suh
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Taek Kyu Park
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joo Myung Lee
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Young Bin Song
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joo-Yong Hahn
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jin-Ho Choi
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Seung-Hyuk Choi
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joong Hyun Ahn
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Keumhee C Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine.,Department of Mathematical and Statistical Sciences, University of Alberta
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine.,Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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115
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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116
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Massart N, Mansour A, Ross JT, Piau C, Verhoye JP, Tattevin P, Nesseler N. Mortality due to hospital-acquired infection after cardiac surgery. J Thorac Cardiovasc Surg 2020; 163:2131-2140.e3. [PMID: 32981703 DOI: 10.1016/j.jtcvs.2020.08.094] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 08/17/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Hospital-acquired infections have been associated with significant morbidity and mortality in critically ill surgical patients. However, little is known about mortality due to hospital-acquired infections in cardiac surgery. METHODS We conducted a retrospective analysis of prospectively collected data from the cardiac surgery unit of a university hospital. All patients who underwent cardiac surgery over a 7-year period were included. Patients with hospital-acquired infections were matched 1:1 with patients with nonhospital-acquired infections based on risk factors for hospital-acquired infections and death after cardiac surgery using propensity score matching. We performed a competitive risk analysis to study the mortality fraction due to hospital-acquired infections. RESULTS Of 8853 patients who underwent cardiac surgery, 370 (4.2%) developed 500 postoperative infections (incidence density rate 4.2 hospital-acquired infections per 1000 patient-days). Crude hospital mortality was significantly higher in patients with hospital-acquired infections than in matched patients who did not develop hospital-acquired infections, 15.4% and 5.7%, respectively (P < .001). The in-hospital mortality fraction due to hospital-acquired infections in our cohort was 17.1% (12.3%-22.8%). Pseudomonas aeruginosa infection (hazard ratio, 2.09; 95% confidence interval, 1.23-3.49; P = .005), bloodstream infection (hazard ratio, 2.08; 95% confidence interval, 1.19-3.63; P = .010), and pneumonia (hazard ratio, 1.68; 95% confidence interval, 1.02-2.77; P = .04) were each independently associated with increased hospital mortality. CONCLUSIONS Although hospital-acquired infections are relatively uncommon after cardiac surgery (4.2%), these infections have a major impact on postoperative mortality (attributable mortality fraction, 17.1%).
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Affiliation(s)
- Nicolas Massart
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; Univ Rennes, CHU de Rennes, Rennes, France; Intensive Care Unit, Hospital of St Brieuc, Saint-Brieuc, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; Univ Rennes, CHU de Rennes, Rennes, France
| | - James T Ross
- Department of Surgery, University of California, San Francisco, Calif
| | - Caroline Piau
- Department of Clinical Microbiology, Rennes University Hospital, Rennes, France
| | - Jean-Philippe Verhoye
- Thoracic and Cardiovascular Surgery Service, Pontchaillou University Hospital Center, University of Rennes 1, Signal and Image Treatment Laboratory (LTSI), National Institute of Health and Medical Research, Rennes, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; Univ Rennes, CHU de Rennes, Inra, Rennes, France; Univ Rennes, CHU Rennes, (Centre d'Investigation Clinique de Rennes), Rennes, France.
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117
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Chehab O, Morsi RZ, Kanj A, Rachwan RJ, Pahuja M, Mansour S, Tabaja H, Ahmad U, Zein SE, Raad M, Saker A, Alvarez P, Briasoulis A. Incidence and clinical outcomes of nosocomial infections in patients presenting with STEMI complicated by cardiogenic shock in the United States. Heart Lung 2020; 49:716-723. [PMID: 32866743 DOI: 10.1016/j.hrtlng.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study addresses the incidence, trends, and impact of nosocomial infections (NI) on the outcomes of patients admitted with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (STEMI-CS) using the United States National Inpatient Sample (NIS) database. METHODS We analyzed data from 105,184 STEMI-CS patients using the NIS database from the years 2005-2014. NI was defined as infections of more than or equal to three days, comprising of central line-associated bloodstream infection (CLABSI), urinary tract infection (UTI), hospital-acquired pneumonia (HAP), Clostridium difficile infection (CDI), bacteremia, and skin related infections. Outcomes of the impact of NI on STEMI-CS included in-hospital mortality, length of hospital stay (LOS) and costs. Significant associations of NI in patients admitted with STEMI-CS were also identified. RESULTS Overall, 19.1% (20,137) of patients admitted with STEMI-CS developed NI. Trends of NI have decreased from 2005-2014. The most common NI were UTI (9.2%), followed by HAP (6.8%), CLABSI (1.5%), bacteremia (1.5%), skin related infections (1.5%), and CDI (1.3%). The strongest association of developing a NI was increasing LOS (7-9 days; OR: 1.99; 95% CI: 1.75-2.26; >9 days; OR: 4.51; 95% CI: 4.04-5.04 compared to 4-6 days as reference). Increased mortality risk among patients with NI was significant, especially those with sepsis-associated NI compared to those without sepsis (OR: 2.95; 95% CI: 2.72-3.20). Patients with NI were found to be associated with significantly longer LOS and higher costs, irrespective of percutaneous mechanical circulatory support placement. CONCLUSIONS NI were common among patients with STEMI-CS. Those who developed NI were at a greater risk of in-hospital mortality, increased LOS and costs.
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Affiliation(s)
- Omar Chehab
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA.
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Amjad Kanj
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rayan Jo Rachwan
- Department of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mohit Pahuja
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Shareef Mansour
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Hussam Tabaja
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Usman Ahmad
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Said El Zein
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mohammad Raad
- Division of Cardiology, Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ali Saker
- Department of Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Paulino Alvarez
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Hessel EA, Betz AC. The Challenges of Venoarterial ECMO for Postcardiotomy Shock. J Cardiothorac Vasc Anesth 2020; 35:48-50. [PMID: 32950347 DOI: 10.1053/j.jvca.2020.08.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 08/23/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Eugene A Hessel
- Department of Anesthesiology, University of Kentucky, Lexington, KY
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Sekandarzad A, Udi J, Waller CF, Bode C, Biever P. Extracorporeal Membrane Oxygenation Support as a Bridge to Recovery during Chemotherapy in a Young Patient with Metastatic Choriocarcinoma and Severe Acute Respiratory Distress Syndrome. Oncol Res Treat 2020; 43:559-564. [PMID: 32810849 DOI: 10.1159/000509428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/14/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A young woman presented at a local hospital with severe dyspnea directly after childbirth. She was di-agnosed with choriocarcinoma and massive pulmonary metastases. Shortly after administration of polychemotherapy she developed severe acute respiratory distress syndrome (ARDS). CASE PRESENTATION The patient was transferred to the intensive care unit (ICU) and extracorporeal membrane oxygenation (ECMO) center of the university hospital. Venovenous ECMO support was implemented for 28 days while enabling continuous chemotherapy. After 49 days in the ICU, she was transferred to the oncology ward in a stable respiratory state. DISCUSSION/CONCLUSION Although the survival rates of ARDS in the general ICU population have improved lately due to improved management of ARDS and ECMO support, the data on adult cancer patients receiving ECMO support are very limited. Only few small retrospective studies on ECMO support in adult cancer patients have been conducted. Unfortunately the survival rates of patients after allogenic hematopoietic stem cell transplantation and ECMO support were discouraging. Nevertheless, cancer patients with at least stable disease who are eligible for full-code ICU management may be potential candidates for ECMO in case of severe ARDS. Our case report not only shows that patients suffering from choriocarcinoma with pulmonary metastases may develop severe ARDS in the context of polychemotherapy, but also demonstrates that ECMO support enables chemotherapy continuation and complete remission of the underlying choriocarcinoma.
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Affiliation(s)
- Asieb Sekandarzad
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, .,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Josefina Udi
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Cornelius F Waller
- Department of Haematology, Oncology and Stem Cell Transplantation, Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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120
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Wang JR, Huang JY, Hu W, Cai XY, Hu WH, Zhu Y. Bloodstream infections in patients undergoing extracorporeal membrane oxygenation. Pak J Med Sci 2020; 36:1171-1176. [PMID: 32968375 PMCID: PMC7501021 DOI: 10.12669/pjms.36.6.2882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: We aimed to evaluate the incidence, risk factors, and prognosis of bloodstream infections (BSIs) during extracorporeal membrane oxygenation (ECMO) treatment in a Chinese population. Methods: Patients receiving ECMO treatment from January 2013 to August 2019 were retrospectively studied. The incidence of BSIs was calculated. The clinical characteristics between patients with a BSI (BSI group) and without a BSI (non-BSI group) Results: Among 69 included patients, 19 (27.5%) developed at least one BSI. Gram-negative bacteria (73.7%) were mainly responsible for the BSIs, with Klebsiella pneumoniae (6/19, 31.5%) ranking as the top related pathogen. The BSI group had a greater proportion of methicillin-resistant Staphylococcus aureus (MRSA) prophylactic regimens (52.6% vs. 26.0%, P = 0.036), a higher pre-ECMO Sequential Organ Failure Assessment (SOFA) score (11 vs. 8, P = 0.008), more applications of continuous renal replacement therapy (CRRT) during ECMO (63.1% vs. 36.1%, P = 0.042). Longer ECMO support duration, period of ventilator use before ECMO weaning and hospital stay were observed in the BSI group. The SOFA score (OR: 1.174; 95% CI: 1.039–1.326; P = 0.010) was an independent risk factor for BSIs. Conclusion: BSIs during ECMO therapy frequently involve Gram-negative bacteria. Stringent care and monitoring should be provided for patients with high SOFA scores.
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Affiliation(s)
- Jian-Rong Wang
- Jian-rong Wang, MS. Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Jin-Yu Huang
- Jin-yu Huang, MD. Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Wei Hu
- Wei Hu, MS. Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Xue-Ying Cai
- Xue-ying Cai, MS. Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Wei-Hang Hu
- Wei-hang Hu, MS. Department of Critical Care Medicine, Zhejiang Hospital, Zhejiang, China
| | - Ying Zhu
- Ying Zhu, MS. Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
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Tohme J, Piat C, Aissat N, Lebreton G, Duceau B, Charfeddine A, Baptiste A, Bouglé A. Weaning-Related Shock in Patients With ECMO: Incidence, Mortality, and Predisposing Factors. J Cardiothorac Vasc Anesth 2020; 35:41-47. [PMID: 32828655 DOI: 10.1053/j.jvca.2020.07.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Venoarterial extracorporeal membrane oxygenation (VA-ECMO) commonly is used to manage refractory cardiogenic shock after cardiac surgery, with 31% to 76% of patients successfully weaned off their ECMO. However, it is associated with high mortality rates, and 20% to 65% of weaned patients do not survive to hospital discharge. This study aimed to assess the incidence of ECMO weaning-related shock, the risk factors, and prognosis in the intensive care unit (ICU). DESIGN Retrospective observational cohort study. SETTING Surgical ICU of Cardiology Institute of Pitié-Salpêtrière University Hospital (Paris-France). PARTICIPANTS Patients who were assisted with a peripheral VA-ECMO from January 2015 to December 2017 were included. Patients with venovenous, central, or right ECMO were excluded. MEASUREMENTS The authors collected data on patients' characteristics, during and after surgery. The indications for VA-ECMO implantation were ventricular dysfunction, primary graft dysfunction, and refractory cardiac arrest. Weaning-related shock was defined as the need to introduce or increase the dose of catecholamine at ECMO explantation or in the following week. RESULTS After weaning off VA-ECMO, 56 of 146 patients (38.4%) presented weaning-related shock: 55% were septic shocks, 12.5 % were caused by right ventricle failure, and 7.1% by hemorrhage. ICU mortality was 42% versus 8% in patients who did not present shock. Multivariate analysis showed that patients with pulmonary hypertension and those with norepinephrine before weaning were more likely to develop shock. CONCLUSION ECMO weaning-related shock is frequent in patients with refractory cardiogenic shock after cardiac surgery. This is most commonly caused by sepsis and causes higher mortality rates, calling for further evaluation.
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Affiliation(s)
- Joanna Tohme
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Camille Piat
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Nadia Aissat
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, AP-HP, Department of Cardio-Vascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Baptiste Duceau
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Ahmed Charfeddine
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Amandine Baptiste
- AP-HP, Hôpital Pitié-Salpêtrière, Département Biostatistique Santé Publique Et Information Médicale, Unité de Recherche Clinique PSL-CFX, Centre de Pharmacoépidémiologie (Cephepi), CIC-1421, Paris, France
| | - Adrien Bouglé
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France.
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Chen WC, Kao KC, Sheu CC, Chan MC, Chen YM, Chien YC, Peng CK, Liang SJ, Hu HC, Tsai MJ, Fang WF, Perng WC, Wang HC, Wu CL, Yang KY. Risk factor analysis of nosocomial lower respiratory tract infection in influenza-related acute respiratory distress syndrome. Ther Adv Respir Dis 2020; 14:1753466620942417. [PMID: 32718277 PMCID: PMC7388104 DOI: 10.1177/1753466620942417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Patients with severe influenza-related acute respiratory distress syndrome
(ARDS) have high morbidity and mortality. Moreover, nosocomial lower
respiratory tract infection (NLRTI) complicates their clinical management
and possibly worsens their outcomes. This study aimed to explore the
clinical features and impact of NLRTI in patients with severe
influenza-related ARDS. Methods: This was an institutional review board approved, retrospective, observational
study conducted in eight medical centers in Taiwan. From January 1 to March
31 in 2016, subjects were enrolled from intensive care units (ICUs) with
virology-proven influenza pneumonia, while all of those patients with ARDS
requiring invasive mechanical ventilation and without bacterial
community-acquired pneumonia (CAP) were analyzed. Baseline characteristics,
critical-illness data and clinical outcomes were recorded. Results: Among the 316 screened patients with severe influenza pneumonia, 250 with
acute respiratory failure requiring intubation met the criteria of ARDS,
without having bacterial CAP. Among them, 72 patients developed NLRTI. The
independent risk factors for NLRTI included immunosuppressant use before
influenza infection [odds ratio (OR), 5.669; 95% confidence interval (CI),
1.770–18.154], extracorporeal membrane oxygenation (ECMO) use after ARDS
(OR, 2.440; 95% CI, 1.214–4.904) and larger corticosteroid dosage after ARDS
(OR, 1.209; 95% CI, 1.038–1.407). Patients with NLRTI had higher in-hospital
mortality and longer ICU stay, hospitalization and duration on mechanical
ventilation. Conclusion: We found that immunosuppressant use before influenza infection, ECMO use, and
larger steroid dosage after ARDS independently predict NLRTI in
influenza-related ARDS. Moreover, NLRTI results in poorer outcomes in
patients with severe influenza. The reviews of this paper are available via the supplemental
material section.
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Affiliation(s)
- Wei-Chih Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei.,Institute of Emergency and Critical Care Medicine and Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Ming-Cheng Chan
- Division of Chest Medicine, Department of Internal Medicine, and Section of Critical Care and Respiratory Therapy, Taichung Veterans General Hospital, Taichung.,Central Taiwan University of Science and Technology, Taichung
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung
| | - Ying-Chun Chien
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan
| | - Ming-Ju Tsai
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung.,Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi
| | - Wann-Cherng Perng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Hao-Chien Wang
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Chieh-Liang Wu
- Center for Quality Management, Taichung Veterans General Hospital, Taichung.,Office of Medical Administration, Taichung Veterans General Hospital, Taichung
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217.,Institute of Emergency and Critical Care Medicine and Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei.,Cancer Progression Research Center, National Yang-Ming University, Taipei
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Winiszewski H, Boyadjian C, Besch G, Perrotti A, Piton G. ECMO cannula-associated infections: interest of cannula swab and subcutaneous needle aspirate samples for prediction of cannula tip culture. Intensive Care Med Exp 2020; 8:35. [PMID: 32705373 PMCID: PMC7378138 DOI: 10.1186/s40635-020-00327-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Hadrien Winiszewski
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France. .,EA3920, University of Franche Comté, Besançon, France.
| | - Charles Boyadjian
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | - Guillaume Besch
- EA3920, University of Franche Comté, Besançon, France.,Surgical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | - Andrea Perrotti
- EA3920, University of Franche Comté, Besançon, France.,Cardiac Surgery Unit, Besançon University Hospital, Besançon, France
| | - Gaël Piton
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France.,EA3920, University of Franche Comté, Besançon, France
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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.
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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
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López-Sánchez M, Moreno-Puigdollers I, Rubio-López MI, Zarragoikoetxea-Jauregui I, Vicente-Guillén R, Argente-Navarro MP. Pharmacokinetics of micafungin in patients treated with extracorporeal membrane oxygenation: an observational prospective study. Rev Bras Ter Intensiva 2020; 32:277-283. [PMID: 32667449 PMCID: PMC7405733 DOI: 10.5935/0103-507x.20200044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/28/2020] [Indexed: 01/19/2023] Open
Abstract
Objective To determine micafungin plasma levels and pharmacokinetic behavior in patients treated with extracorporeal membrane oxygenation. Methods The samples were taken through an access point before and after the membrane in two tertiary hospitals in Spain. The times for the calculation of pharmacokinetic curves were before the administration of the drug and 1, 3, 5, 8, 18 and 24 hours after the beginning of the infusion on days one and four. The area under the curve, drug clearance, volume of distribution and plasma half-life time with a noncompartmental pharmacokinetic data analysis were calculated. Results The pharmacokinetics of the values analyzed on the first and fourth day of treatment did not show any concentration difference between the samples taken before the membrane (Cin) and those taken after the membrane (Cout), and the pharmacokinetic behavior was similar with different organ failures. The area under the curve (AUC) before the membrane on day 1 was 62.1 (95%CI 52.8 - 73.4) and the AUC after the membrane on this day was 63.4 (95%CI 52.4 - 76.7), p = 0.625. The AUC before the membrane on day 4 was 102.4 (95%CI 84.7 - 142.8) and the AUC was 100.9 (95%CI 78.2 - 138.8), p = 0.843. Conclusion The pharmacokinetic parameters of micafungin were not significantly altered.
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Affiliation(s)
- Marta López-Sánchez
- Departamento de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Espanha
| | | | - Maria Isabel Rubio-López
- Departamento de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Espanha
| | | | - Rosario Vicente-Guillén
- Departamento de Anestesiologia e Reanimação, Hospital Universitario La Fé, Valencia, Espanha
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126
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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.
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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
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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.
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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
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128
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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: 14] [Impact Index Per Article: 3.5] [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.
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Abstract
Sepsis is being recognized as an important complication of extracorporeal membrane oxygenation (ECMO) and its presence is a poor prognostic marker and increases the overall mortality. The survival rate differs in the various types of cannulation techniques. Adult patients with prolonged duration of ECMO constitute the major risk population. Ventilator-associated pneumonia and bloodstream infections form the main sources of sepsis in these patients. It is important to know the most common etiological agents for sepsis in ECMO, which varies partly with the local epidemiology of the hospitals. A high index of suspicion, drawing adequate volumes for blood culture and early and timely administration of appropriate empirical antimicrobials can substantially decrease the morbidity and mortality in this high-risk population. The dosing of antimicrobials is influenced by the pharmacological variations on ECMO machine and is an important consideration. Infection control practices are of paramount importance and need to be followed meticulously to prevent sepsis in ECMO.
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130
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Coutance G, Jacob N, Demondion P, Nguyen LS, Bouglé A, Bréchot N, Varnous S, Leprince P, Combes A, Lebreton G. Favorable Outcomes of a Direct Heart Transplantation Strategy in Selected Patients on Extracorporeal Membrane Oxygenation Support. Crit Care Med 2020; 48:498-506. [PMID: 32205596 DOI: 10.1097/ccm.0000000000004182] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Heart transplantation in patients supported by venoarterial extracorporeal membrane oxygenation has been associated with poor prognosis. A specific protocol for extracorporeal membrane oxygenation management encompassing patient selection, implantation strategy, and preoperative and perioperative treatment is applied at our institution. Our aim was to compare posttransplant outcomes of patients supported or not by extracorporeal membrane oxygenation at the time of heart transplantation. DESIGN A large observational single-center retrospective study was conducted. The primary endpoint was overall survival after heart transplantation. Secondary endpoints included death-censored rejection-free survival and the frequency of extracorporeal membrane oxygenation-related complications. SETTING One heart transplantation and extracorporeal membrane oxygenation high-volume center. PATIENTS All consecutive patients over 18 years old with a first noncombined heart transplantation performed between 2012 and 2016 were included. INTERVENTIONS None (retrospective observational study). MEASUREMENTS AND MAIN RESULTS Among the 415 transplanted patients, 118 (28.4%) were on extracorporeal membrane oxygenation at the time of transplantation (peripheral, 94%; intrathoracic, 6%). Median time on extracorporeal membrane oxygenation before heart transplantation was 9 days (interquartile range, 5-15 d) and median follow-up post heart transplantation was 20.7 months. Posttransplant survival did not differ significantly between the two groups (1-yr survival = 85.5% and 80.7% in extracorporeal membrane oxygenation vs nonextracorporeal membrane oxygenation patients; hazard ratio, 0.69; 95% CI, 0.43-1.11; p = 0.12, respectively). Donor age, body mass index, creatinine clearance, and ischemic time were independently associated with overall mortality, but not extracorporeal membrane oxygenation at the time of heart transplantation. Rejection-free survival also did not significantly differ between groups (hazard ratio, 0.85; 95% CI, 0.60-1.23; p = 0.39). Local wound infection was the most frequent complication after extracorporeal membrane oxygenation (37% of patients). CONCLUSIONS With the implementation of a specific protocol, patients bridged to heart transplantation on extracorporeal membrane oxygenation had similar survival compared with those not supported by extracorporeal membrane oxygenation.
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Affiliation(s)
- Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | | | - Pierre Demondion
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Lee S Nguyen
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Adrien Bouglé
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Nicolas Bréchot
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Shaida Varnous
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrieère Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
- INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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131
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Cannula-Related Infection in Patients Supported by Peripheral ECMO: Clinical and Microbiological Characteristics. ASAIO J 2020. [PMID: 29517513 DOI: 10.1097/mat.0000000000000771] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Little is known about cannula-related infection (CRI) in patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to assess the incidence, the risk factors, prognosis, and microbiological characteristics of CRI in patients supported by ECMO. This retrospective cohort study was conducted in one intensive care unit (ICU). Among 220 consecutive patients with peripheral ECMO, 39 (17.7%) developed CRI. The incidence of CRI was 17.2 per 1,000 ECMO days. The main isolated microorganisms were Enterobacteriaceae (38%), Staphylococcus spp. (28.2%; 8.5% were methicillin-sensitive Staphylococcus aureus and 19.7% were coagulase-negative staphylococci), and Pseudomonas aeruginosa (18.3%). Bacteremia was present in 23 cases (59.7%). In multivariate analysis, the risk factors for CRI were longer ECMO duration (p = 0.006) and higher Simplified Acute Physiology Score 2 (p = 0.004). Forty-one percentage of patients with CRI needed surgical management of the infected site. Cannula-related infection was not associated with higher in-hospital mortality (p = 0.73), but it was associated with a longer stay in ICU (p < 0.0001) and a longer stay in hospital (p = 0.002). In conclusion, CRI is frequent in patients with ECMO and associated with a longer stay in hospital. Risk factors for CRI were longer ECMO duration and higher Simplified Acute Physiology Score 2. Concomitant bacteremia was frequent (59.7%) and CRI should be strongly investigated in cases of positive blood culture.
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132
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Nosocomial Infections During Extracorporeal Membrane Oxygenation in Neonatal, Pediatric, and Adult Patients: A Comprehensive Narrative Review. Pediatr Crit Care Med 2020; 21:283-290. [PMID: 31688809 DOI: 10.1097/pcc.0000000000002190] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is increasingly used in critically ill patients with refractory cardiopulmonary failure. Nosocomial infection acquired during extracorporeal membrane oxygenation represents one of the most frequent complications but the available evidence on the risk of infection and its association with outcomes has not been comprehensively analyzed. We performed a narrative review examining the epidemiology of nosocomial infection during extracorporeal membrane oxygenation, association with clinical outcomes, and preventive strategies. DATA SOURCES We searched PubMed, Web of Science, EMBASE, and the Cochrane Library between 1972 and June 2018. STUDY SELECTION We included any article which detailed nosocomial infection during extracorporeal membrane oxygenation. Articles were excluded if they were not written in English, detailed extracorporeal membrane oxygenation use for infections acquired prior to extracorporeal membrane oxygenation, or used other forms of extracorporeal support such as ventricular assist devices. DATA EXTRACTION Two reviewers independently assessed eligibility and extracted data. We screened 984 abstracts and included 59 articles in the final review. DATA SYNTHESIS The reported risk of nosocomial infection among patients receiving extracorporeal membrane oxygenation ranged from 3.5% to 64% per extracorporeal membrane oxygenation run, while the incidence of infection ranged from 10.1 to 116.2/1,000 extracorporeal membrane oxygenation days. Nosocomial infections during extracorporeal membrane oxygenation were consistently associated with longer duration of extracorporeal membrane oxygenation and, in several large multicenter studies, with increased mortality. Risk factors for nosocomial infection included duration of extracorporeal membrane oxygenation, mechanical and hemorrhagic complications on extracorporeal membrane oxygenation, and use of venoarterial and central extracorporeal membrane oxygenation. Biomarkers had low specificity for infection in this population. Few studies examined strategies on how to prevent nosocomial infection on extracorporeal membrane oxygenation. CONCLUSIONS Nosocomial infections in extracorporeal membrane oxygenation patients are common and associated with worse outcomes. There is substantial variation in the rates of reported infection, and thus, it is possible that some may be preventable. The evidence for current diagnostic, preventive, and therapeutic strategies for infection during extracorporeal membrane oxygenation is limited and requires further investigation.
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133
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Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med 2020; 46:266-284. [PMID: 32047941 PMCID: PMC7223992 DOI: 10.1007/s00134-020-05950-6] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
Bloodstream infection (BSI) is defined by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary—that is, without identified origin. Community-acquired BSIs in immunocompetent adults usually involve drug-susceptible bacteria, while healthcare-associated BSIs are frequently due to multidrug-resistant (MDR) strains. Early adequate antimicrobial therapy is a key to improve patient outcomes, especially in those with criteria for sepsis or septic shock, and should be based on guidelines and direct examination of available samples. Local epidemiology, suspected source, immune status, previous antimicrobial exposure, and documented colonization with MDR bacteria must be considered for the choice of first-line antimicrobials in healthcare-associated and hospital-acquired BSIs. Early genotypic or phenotypic tests are now available for bacterial identification and early detection of resistance mechanisms and may help, though their clinical impact warrants further investigations. Initial antimicrobial dosing should take into account the pharmacokinetic alterations commonly observed in ICU patients, with a loading dose in case of sepsis or septic shock. Initial antimicrobial combination attempting to increase the antimicrobial spectrum should be discussed when MDR bacteria are suspected and/or in the most severely ill patients. Source identification and control should be performed as soon as the hemodynamic status is stabilized. De-escalation from a broad-spectrum to a narrow-spectrum antimicrobial may reduce antibiotic selection pressure without negative impact on mortality. The duration of therapy is usually 5–8 days though longer durations may be discussed depending on the underlying illness and the source of infection. This narrative review covers the epidemiology, diagnostic workflow and therapeutic aspects of BSI in ICU patients and proposed up-to-date expert statements.
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Affiliation(s)
- Jean-François Timsit
- AP-HP, Hôpital Bichat, Medical and Infectious Diseases ICU, 75018, Paris, France. .,Université de Paris, IAME, INSERM, 75018, Paris, France.
| | - Etienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.,AP-HP, Hôpital Bichat, Bacteriology Laboratory, 75018, Paris, France
| | | | - Alexis Tabah
- ICU, Redcliffe Hospital, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino-IRCCS, Genoa, Italy
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134
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Neonatal respiratory extracorporeal membrane oxygenation and primary diagnosis: trends between two decades. J Perinatol 2020; 40:269-274. [PMID: 31700091 DOI: 10.1038/s41372-019-0547-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Examine changing neonatal respiratory extracorporeal membrane oxygenation (ECMO) practice trends and outcomes. STUDY DESIGN Retrospective cohort study comparing neonatal respiratory ECMO in the 1990 and 2010 decades (1994-1995 and 2014-2015). Patients ≤ 30 days of life, reported to the Extracorporeal Life Support Organization registry, were included. RESULTS Four thousand one hundred and twenty-five patients met inclusion criteria. ECMO cases decreased by 33%. The primary ECMO diagnosis changed significantly over time (p < 0.0001). Survival to discharge decreased (76 vs 67%, p < 0.0001) and ECMO duration increased (131 vs 158 h, p < 0.001). Lung recovery was the most common reason to discontinue ECMO although family request for withdrawal and a diagnosis considered "incompatible with life" was increasingly common in the 2010s. CONCLUSION Although the use of ECMO for neonatal respiratory diagnoses has decreased over time, its use has increased for patients with more complex diagnoses and ECMO duration is longer. ECMO continues to be an important supportive therapy, improved understanding of which patients would benefit most is needed.
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135
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Vidal C, Pasqualotto R, James A, Dureau P, Rasata J, Coutance G, Varnous S, Leprince P, Amour J, Bouglé A. Predictive risk factors for postoperative pneumonia after heart transplantation. BMC Anesthesiol 2020; 20:8. [PMID: 31910812 PMCID: PMC6947950 DOI: 10.1186/s12871-019-0923-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 12/27/2019] [Indexed: 01/28/2023] Open
Abstract
Background Pneumonia is a frequent complication in patients undergoing heart transplantation (HTx) that increases morbidity and mortality in this population. Nevertheless, the risk factors for postoperative pneumonia (POP) are still unknown. The aim of this study was to investigate the predictive risk factors for POP in HTx recipients. Methods In this retrospective study, all patients undergoing HTx between January 2014 and December 2015 were included. All cases of POP occurring until hospital discharge were investigated. The study aimed to determine risk factors using univariate and multivariate Cox regression models. Data are expressed in Odds Ratio [95% CI]. P < 0.05 was necessary to reject the null hypothesis. Results A total of 175 patients were included without any patients being lost to follow-up, and 89 instances of POP were diagnosed in 59 (34%) patients. Enterobacteriaceae and Pseudomonas aeruginosa were the most common pathogens. In the multivariate analysis, the risk factors were preoperative mechanical ventilation (OR 1.42 [1.12–1.80], P < 0.01) and perioperative blood transfusion (OR 1.42 [95% CI: 1.20–1.70], P < 0.01). POP significantly impacted mortality at 30 days (OR: 4 [1.3–12.4], P = 0.01) and 1 year (OR: 6.8 [2.5–8.4], P < 0.01) and was associated with a longer duration of mechanical ventilation, time to weaning from venoarterial extracorporeal membrane oxygenation and stay in an intensive care unit. Plasma exchanges and intravenous administration of immunoglobulins did not increase the risk of POP. Conclusion After HTx, preoperative mechanical ventilation and blood transfusion were risk factors for POP and were associated with increased mortality. Enterobacteriaceae and Pseudomonas aeruginosa are the most common pathogens of POP.
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Affiliation(s)
- Charles Vidal
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France. .,Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France.
| | - Romain Pasqualotto
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France
| | - Arthur James
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France
| | - Pauline Dureau
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France
| | - Julie Rasata
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France
| | - Guillaume Coutance
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Allée des Topazes, 97400, Saint Denis de la Réunion, France
| | - Shaida Varnous
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Allée des Topazes, 97400, Saint Denis de la Réunion, France
| | - Pascal Leprince
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Allée des Topazes, 97400, Saint Denis de la Réunion, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France
| | - Adrien Bouglé
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Paris, France
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136
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Bull T, Corley A, Lye I, Spooner AJ, Fraser JF. Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries. PLoS One 2019; 14:e0227248. [PMID: 31887197 PMCID: PMC6936833 DOI: 10.1371/journal.pone.0227248] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/15/2019] [Indexed: 01/05/2023] Open
Abstract
Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres 'always' suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that 'never' sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement.
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Affiliation(s)
- Taressa Bull
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - India Lye
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - Amy J. Spooner
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - John F. Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
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137
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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: 60] [Impact Index Per Article: 12.0] [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.
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138
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[Clinical pharmacokinetics of anti-infective drugs in extracorporeal membrane oxygenation]. Anaesthesist 2019; 68:821-826. [PMID: 31740986 DOI: 10.1007/s00101-019-00702-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming more and more clinically important. The extracorporeal circuit for membrane oxygenation consists of a pump, a membrane oxygenator and large volume tubing. The ECMO device forms an additional compartment, which can absorb drugs with high lipophilia and protein binding. Thus, ECMO affects the volume of distribution and the clearance. As a consequence, the pharmacokinetic-pharmacodynamic (pk-pd) target parameters cannot be achieved. The selection of an appropriate substance and the mode of application, combined with therapeutic drug monitoring (TDM), can significantly improve the therapeutic outcome of critically ill patients.
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139
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Marcus JE, Piper LC, Ainsworth CR, Sams VG, Batchinsky A, Okulicz JF, Barsoumian AE. Infections in patients with burn injuries receiving extracorporeal membrane oxygenation. Burns 2019; 45:1880-1887. [PMID: 31601427 DOI: 10.1016/j.burns.2019.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) has only recently been described in patients with burn injuries. We report the incidence and type of infections in critically ill burn and non-burn patients receiving ECMO. METHODS A retrospective chart review was performed on all patients at Brooke Army Medical Center who received ECMO between September 2012 and May 2018. RESULTS 78 patients underwent ECMO. Approximately half were men with a median age of 34 years with a median time on ECMO of 237 h (IQR 121-391). Compared to patients without burns (n = 58), patients with burns (n = 20) had no difference in time on ECMO, but had more overall infections (86 vs. 31 per 1000 days, p = 0.0002), respiratory infections (40 vs. 15 per 1000 days, p = 0.01), skin and soft tissue infections (21 vs. 5 per 1000 days, p = 0.02) and fungal infections (35% vs 10%, p = 0.02). Twenty percent of bacterial burn infections were due to drug resistant organisms. CONCLUSION This is the first study to describe the incidence of infection in burn injury patients who are undergoing ECMO. We observed an increase in infections in burn patients on ECMO compared to non-burn patients. ECMO remains a viable option for critically ill patients with burn injuries.
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Affiliation(s)
- Joseph E Marcus
- Department of Internal Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States.
| | - Lydia C Piper
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brook Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Craig R Ainsworth
- U.S. Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, United States
| | - Valerie G Sams
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brook Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Andriy Batchinsky
- U.S. Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, United States
| | - Jason F Okulicz
- Infectious Disease Service, MCHE-MDI, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Alice E Barsoumian
- Infectious Disease Service, MCHE-MDI, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
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de Roux Q, Botterel F, Lepeule R, Taccone FS, Langeron O, Mongardon N. Candida bloodstream infection under veno-arterial ECMO therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:314. [PMID: 31530278 PMCID: PMC6747746 DOI: 10.1186/s13054-019-2593-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Quentin de Roux
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale cardio-vasculaire, DMU CARE, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.,U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | - Françoise Botterel
- Unité de Parasitologie-Mycologie, Département des agents infectieux, Assistance Publique des Hôpitaux de Paris (APHP), Centre Hospitalier Universitaire Henri Mondor, Créteil, France.,Université Paris Est Créteil, Faculté de Médecine, Créteil, France
| | - Raphaël Lepeule
- Unité transversale de traitement des infections, Département des agents infectieux, Assistance Publique des Hôpitaux de Paris (APHP), Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Clinique Universitaire de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Olivier Langeron
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale cardio-vasculaire, DMU CARE, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.,Université Paris Est Créteil, Faculté de Médecine, Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale cardio-vasculaire, DMU CARE, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France. .,U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France. .,Université Paris Est Créteil, Faculté de Médecine, Créteil, France.
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Rambaud J, Allioux C, Jean S, Guilbert J, Guellec I, Demoulin M, Carbajal R, Guedj R, Leger PL. Nosocomial Infections in Neonates Supported by Extracorporeal Membrane Oxygenation: First French Retrospective Study. Indian J Crit Care Med 2019; 23:392-395. [PMID: 31645822 PMCID: PMC6775718 DOI: 10.5005/jp-journals-10071-23231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Rambaud J, Allioux C, Jean S, Guilbert J, Guellec I, Demoulin M, et al. Nosocomial Infections in Neonates Supported by Extracorporeal Membrane Oxygenation: First French Retrospective Study. Indian J Crit Care Med 2019;23(9):392–395.
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Affiliation(s)
- Jerome Rambaud
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
- Jerome Rambaud, Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France, Phone: 33-33-0171738527, e-mail:
| | - Cecile Allioux
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Sandrine Jean
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Julia Guilbert
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Isabelle Guellec
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Maryne Demoulin
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Ricardo Carbajal
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Romain Guedj
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
| | - Pierre Louis Leger
- Neonatal and Pediatric Intensive Care Unit, Armand-Trousseau Hospital, Paris, France
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McGugan PL. The Role of Venoarterial Extracorporeal Membrane Oxygenation in Postcardiotomy Cardiogenic Shock. Crit Care Nurs Clin North Am 2019; 31:419-436. [DOI: 10.1016/j.cnc.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Corley A, Lye I, Lavana JD, Ahuja A, Anstey CM, Jarrett P, Haisz E, Parke R, Pellegrino V, Buscher H, Fraser JF. Nosocomial infection prevalence in patients undergoing extracorporeal membrane oxygenation (ECMO): protocol for a point prevalence study across Australia and New Zealand. BMJ Open 2019; 9:e029293. [PMID: 31296512 PMCID: PMC6624104 DOI: 10.1136/bmjopen-2019-029293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) provides cardiac and/or respiratory support when other therapies fail. Nosocomial infection is reported in up to 64% of patients receiving ECMO and increases morbidity and mortality. These patients are at high risk of infection due, in part, to the multiple invasive devices required in their management, the largest being the cannulae through which ECMO is delivered. Prevalence of nosocomial infection in ECMO patients, including ECMO cannula-related infection, is not well described across Australia and New Zealand. METHODS AND ANALYSIS This is a prospective, observational point prevalence study of 12 months duration conducted at 11 ECMO centres across Australia and New Zealand. Data will be collected for every patient receiving ECMO during 12 predetermined data collection weeks. The primary outcome is the prevalence of laboratory-confirmed bloodstream infection, and suspected or probable nosocomial infections; and the secondary outcomes include describing ECMO cannula dressing and securement practices, and adherence to local dressing and securement guidelines. Data collection will be finalised by March 2019. ETHICS AND DISSEMINATION Relevant ethical and governance approvals have been received. Study results will describe the prevalence of suspected and confirmed nosocomial infection in adult, paediatric and neonatal patients receiving ECMO across Australia and New Zealand. It is expected that the results will be hypothesis generating and lead to interventional trials aimed at reducing the high infection rates seen in this cohort. Results will be published in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER ANZCTRN12618001109291; Pre-results.
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Affiliation(s)
- Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - India Lye
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Jayshree D Lavana
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Abhilasha Ahuja
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Chris M Anstey
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- School of Medicine, Griffith University, Birtinya, Queensland, Australia
| | - Paul Jarrett
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Emma Haisz
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, South Brisbane, Queensland, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Vincent Pellegrino
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
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145
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Extracorporeal Membrane Oxygenation-Associated Infections: Carefully Consider Cannula Infections! Crit Care Med 2019; 46:e171-e172. [PMID: 29337807 DOI: 10.1097/ccm.0000000000002790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The authors reply. Crit Care Med 2019; 46:e172-e173. [PMID: 29337808 DOI: 10.1097/ccm.0000000000002852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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147
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Infections on Extracorporeal Life Support in Adults and Children-A Survey of International Practice on Prevention, Diagnosis, and Treatment. Pediatr Crit Care Med 2019; 20:667-671. [PMID: 31136375 DOI: 10.1097/pcc.0000000000001941] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess nosocomial infection management practices in pediatric and adult patients supported with extracorporeal life support. DESIGN A 23-question online survey was developed to assess practices related to infection prevention, surveillance, diagnosis, and treatment in patients managed on extracorporeal life support. The survey was distributed internationally to intensivists via online newsletters and e-mail from June to December 2017. SETTING Extracorporeal life support centers. SUBJECTS Intensivists working in extracorporeal life support centers. INTERVENTIONS None. RESULTS We analyzed 147 responses from 25 countries. Most centers have bundles implemented as standard of care to prevent against ventilator-associated pneumonia (77%) and central catheter-associated bloodstream infections (91%). Prophylactic antibiotics beyond cannulation are at least occasionally used by 61% of respondents. Daily C-reactive protein (35%) and white cell count (80%) are the most commonly used surveillance biomarkers, and 25% of respondents reported collecting daily surveillance cultures. Participants responded that new onset of hemodynamic instability and rising C-reactive protein (49%) or rising procalcitonin (30%) are the most common triggers to commence antibiotics. CONCLUSION There is considerable variability surrounding practices on prevention and diagnosis of infection in patients treated with extracorporeal life support. In view of the impact of infections acquired during extracorporeal life support, further research to inform recommendations on prevention, diagnosis, and management of infection on extracorporeal life support is urgently needed.
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Burrell AJC, Bennett V, Serra AL, Pellegrino VA, Romero L, Fan E, Brodie D, Cooper DJ, Kaye DM, Fraser JF, Hodgson CL. Venoarterial extracorporeal membrane oxygenation: A systematic review of selection criteria, outcome measures and definitions of complications. J Crit Care 2019; 53:32-37. [PMID: 31181462 DOI: 10.1016/j.jcrc.2019.05.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 04/28/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to systematically investigate the reporting of selection criteria and outcome measures, and to examine definitions of complications used in venoarterial extracorporeal membrane oxygenation studies (V-A ECMO). MATERIALS AND METHODS Medline, EMBASE and the Cochrane central register were searched for V-A ECMO studies from January 2005 to July 2017. Studies with ≤99 patients or without patient centered outcomes were excluded. Two reviewers independently assessed search results and undertook data extraction. RESULTS Forty-six studies met the inclusion criteria, and all were retrospective, observational studies. Inconsistent reporting of selection criteria, ECMO management and outcome measures was common. In-hospital mortality was the most common primary outcome (41% of studies), followed by 30-day mortality (11%). Bleeding was the most frequent complication reported, most commonly defined as "bleeding requiring transfusion" (median ≥ 2 Units/day). Significant variation in reporting and definitions was also evident for vascular, neurological renal and infectious complications. CONCLUSION This systematic review provides clinicians with the most commonly reported selection criteria, outcome measures and complications used in ECMO practice. However non-standardized definitions and inconsistent reporting limits their ability to inform practice. New consensus driven definitions of complications and patient centred outcomes are urgently needed.
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Affiliation(s)
- Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Victoria Bennett
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Alexis L Serra
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - Vincent A Pellegrino
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - David M Kaye
- Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia.
| | - John F Fraser
- Critical Care Research Group Adult Intensive Care Service, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
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Pozzi M, Flagiello M, Armoiry X, Generali T, Adamou Nouhou K, Koffel C, Schweizer R, Fellahi JL, Cuenin L, Cellier G, Green L, Derimay F, Rioufol G, Finet G, Obadia JF. Extracorporeal life support in the multidisciplinary management of cardiogenic shock complicating acute myocardial infarction. Catheter Cardiovasc Interv 2019; 95:E71-E77. [DOI: 10.1002/ccd.28316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 02/03/2019] [Accepted: 04/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Michele Flagiello
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Xavier Armoiry
- Division of Health SciencesUniversity of Warwick, Warwick Medical School Coventry England
| | - Tommaso Generali
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Kaled Adamou Nouhou
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Catherine Koffel
- Department of Anesthesia and ICU“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Remi Schweizer
- Department of Anesthesia and ICU“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Jean Luc Fellahi
- Department of Anesthesia and ICU“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Leo Cuenin
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Guillaume Cellier
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Lisa Green
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Francois Derimay
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Gilles Rioufol
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Gerard Finet
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Jean Francois Obadia
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
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Bouglé A, Dujardin O, Lepère V, Ait Hamou N, Vidal C, Lebreton G, Salem JE, El-Helali N, Petijean G, Amour J. PHARMECMO: Therapeutic drug monitoring and adequacy of current dosing regimens of antibiotics in patients on Extracorporeal Life Support. Anaesth Crit Care Pain Med 2019; 38:493-497. [PMID: 30831307 DOI: 10.1016/j.accpm.2019.02.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/21/2019] [Accepted: 02/23/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Optimisation of antibiotic therapy for extracorporeal membrane oxygenation (ECMO) patients remains a pharmacological challenge. The objective of this study was to observe the plasma concentrations of commonly used antibiotics in intensive care for patients treated with extracorporeal membrane oxygenation. PATIENTS AND METHODS The PHARMECMO study was a pilot, prospective study, conducted in a cardiac surgery intensive care unit. Every adult patient under ECMO support, with known or suspected sepsis and receiving antibiotic therapy, was eligible for inclusion. Plasma concentrations of antibiotics were determined by a combination of liquid chromatography and mass spectrometry. RESULTS Forty-four eligible patients were enrolled for 68 inclusions on a twelve-month period. For the association piperacillin-tazobactam (n=19), 68.7% of CT50 and 93.7% of Cmin reached the pharmacokinetic goals defined (64 mg.L-1 for CT50 and 16 mg.L-1 for Cmin). For cefotaxime (n=12), the pharmacokinetic goals (4 mg.L-1 for CT50 and 1 mg.L-1 for Cmin) were achieved in 100% of the cases for CT50 and in 81.8% of the cases for Cmin. Regarding imipenem (n=10), the pharmacokinetic goals were 16 mg.L-1 for CT50 and 4 mg.L-1 for Cmin. Only one CT50 was above 16 mg.L-1. For Cmin, 60% of the doses did not reach the target concentration. In our 10 patients, only one patient was considered as reaching the pharmacokinetic goals. Finally, for amikacin (n=6), four Cmax (66.7%) were infra-therapeutics for a target between 60 and 80 mg.L-1. CONCLUSION These preliminary results suggest that therapeutic drug monitoring could optimise the achievement of pharmacokinetic objectives associated with an effective antibiotic therapy. For most patients, the recommended doses of imipenem and amikacin did not achieve the pK targets.
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Affiliation(s)
- Adrien Bouglé
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France.
| | - Olivier Dujardin
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Victoria Lepère
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Nora Ait Hamou
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles Vidal
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Cardio-Vascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Najoua El-Helali
- Department of Clinical Microbiology and Therapeutic Monitoring of Anti-infective drugs, Hospital Group Paris Saint-Joseph, Paris, France
| | - Grégoire Petijean
- Department of Clinical Microbiology and Therapeutic Monitoring of Anti-infective drugs, Hospital Group Paris Saint-Joseph, Paris, France
| | - Julien Amour
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
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