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Priddy CMO, Kajimoto M, Ledee DR, Bouchard B, Isern N, Olson AK, Des Rosiers C, Portman MA. Myocardial oxidative metabolism and protein synthesis during mechanical circulatory support by extracorporeal membrane oxygenation. Am J Physiol Heart Circ Physiol 2012. [PMID: 23203964 DOI: 10.1152/ajpheart.00672.2012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides essential mechanical circulatory support necessary for survival in infants and children with acute cardiac decompensation. However, ECMO also causes metabolic disturbances, which contribute to total body wasting and protein loss. Cardiac stunning can also occur, which prevents ECMO weaning, and contributes to high mortality. The heart may specifically undergo metabolic impairments, which influence functional recovery. We tested the hypothesis that ECMO alters oxidative metabolism and protein synthesis. We focused on the amino acid leucine and integration with myocardial protein synthesis. We used a translational immature swine model in which we assessed in heart 1) the fractional contribution of leucine (FcLeucine) and pyruvate to mitochondrial acetyl-CoA formation by nuclear magnetic resonance and 2) global protein fractional synthesis (FSR) by gas chromatography-mass spectrometry. Immature mixed breed Yorkshire male piglets (n = 22) were divided into four groups based on loading status (8 h of normal circulation or ECMO) and intracoronary infusion [(13)C(6),(15)N]-L-leucine (3.7 mM) alone or with [2-(13)C]-pyruvate (7.4 mM). ECMO decreased pulse pressure and correspondingly lowered myocardial oxygen consumption (∼40%, n = 5), indicating decreased overall mitochondrial oxidative metabolism. However, FcLeucine was maintained and myocardial protein FSR was marginally increased. Pyruvate addition decreased tissue leucine enrichment, FcLeucine, and Fc for endogenous substrates as well as protein FSR. The heart under ECMO shows reduced oxidative metabolism of substrates, including amino acids, while maintaining 1) metabolic flexibility indicated by ability to respond to pyruvate and 2) a normal or increased capacity for global protein synthesis.
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152
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Scolletta S, Buonamano A, Sottili M, Giomarelli P, Biagioli B, Vannelli GB, Serio M, Romagnani P, Crescioli C. CXCL10 release in cardiopulmonary bypass: An in vivo and in vitro study. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.biomag.2011.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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153
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Rungatscher A, Merlini A, De Rita F, Lucchese G, Barozzi L, Faggian G, Mazzucco A, Luciani GB. Diagnosis of infection in paediatric veno-arterial cardiac extracorporeal membrane oxygenation: role of procalcitonin and C-reactive protein. Eur J Cardiothorac Surg 2012; 43:1043-9. [DOI: 10.1093/ejcts/ezs524] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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154
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Shekar K, Roberts JA, Mullany DV, Corley A, Fisquet S, Bull TN, Barnett AG, Fraser JF. Increased sedation requirements in patients receiving extracorporeal membrane oxygenation for respiratory and cardiorespiratory failure. Anaesth Intensive Care 2012; 40:648-55. [PMID: 22813493 DOI: 10.1177/0310057x1204000411] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Critically ill patients receiving extracorporeal membrane oxygenation (ECMO) are often noted to have increased sedation requirements. However, data related to sedation in this complex group of patients is limited. The aim of our study was to characterise the sedation requirements in adult patients receiving ECMO for cardiorespiratory failure. A retrospective chart review was performed to collect sedation data for 30 consecutive patients who received venovenous or venoarterial ECMO between April 2009 and March 2011. To test for a difference in doses over time we used a regression model. The dose of midazolam received on ECMO support increased by an average of 18 mg per day (95% confidence interval 8, 29 mg, P=0.001), while the dose of morphine increased by 29 mg per day (95% confidence interval 4, 53 mg, P=0.021) The venovenous group received a daily midazolam dose that was 157 mg higher than the venoarterial group (95% confidence interval 53, 261 mg, P=0.005). We did not observe any significant increase in fentanyl doses over time (95% confidence interval 1269, 4337 µg, P=0.94). There is a significant increase in dose requirement for morphine and midazolam during ECMO. Patients on venovenous ECMO received higher sedative doses as compared to patients on venoarterial ECMO. Future research should focus on mechanisms behind these changes and also identify drugs that are most suitable for sedation during ECMO.
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Affiliation(s)
- K Shekar
- Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia.
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155
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Nakagiri T, Inoue M, Nakagawa J, Okumura M. Blunt Tracheal Transection Repair Requiring Open Abdominal Management. Ann Thorac Surg 2011; 92:2248-50. [DOI: 10.1016/j.athoracsur.2011.05.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 05/24/2011] [Accepted: 05/31/2011] [Indexed: 11/28/2022]
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156
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157
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Park PK, Napolitano LM, Bartlett RH. Extracorporeal Membrane Oxygenation in Adult Acute Respiratory Distress Syndrome. Crit Care Clin 2011; 27:627-46. [DOI: 10.1016/j.ccc.2011.05.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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158
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Bilen O, Loftis L, Teruya J. Severe thrombotic and bleeding complications in a baby with heterozygous factor V Leiden and acquired von Willebrand disease on ECMO. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2011; 43:64-69. [PMID: 21848174 PMCID: PMC4680025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 05/02/2011] [Indexed: 05/31/2023]
Abstract
We aim to present the case of a 5-week-old girl with severe respiratory failure placed on veno-venous extracorporeal membrane oxygenation (ECMO) that was then switched to veno-arterial ECMO. She required up to 60 units/kg/hr of heparin to keep her heparin level within the target range at .3-.7 units/mL. During the ECMO course, substantial thrombus formation was observed within the venous site of the ECMO cannula, which led to two circuit changes on ECMO day 9 and day 20. On ECMO day 15, she was noticed to have purpuric lesions on her chest and her right hand with no obvious arterial or venous clot detected by Doppler ultrasound. She was also noted to have remarkable hemolysis as the plasma free hemoglobin levels were substantially elevated up to 700 mg/dL. She was noted to have continuous oozing from the catheter insertion sites despite adequate underlying coagulation status. Her subsequent platelet function analysis, the thromboelastography, and thromboelastography platelet mapping suggested substantial platelet dysfunction. Her von Willebrand panel revealed absence of high molecular weight multimers. Further coagulation workup was prompted which revealed heterozygosity for factor V Leiden. The patient developed severe pulmonary hemorrhages and ECMO was discontinued on day 40.
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Affiliation(s)
- Ozlem Bilen
- Department of Pathology and Immunology, Baylor College of Medicine, Division of Transfusion Medicine and Coagulation, Texas Children’s Hospital, Houston, Texas, Texas Children’s Hospital, Houston, Texas
| | - Laura Loftis
- Department of Pediatrics, Baylor College of Medicine, Division of Transfusion Medicine and Coagulation, Texas Children’s Hospital, Houston, Texas, Texas Children’s Hospital, Houston, Texas
- Section of Critical Care Medicine, Baylor College of Medicine, Division of Transfusion Medicine and Coagulation, Texas Children’s Hospital, Houston, Texas, Texas Children’s Hospital, Houston, Texas
| | - Jun Teruya
- Department of Pathology and Immunology, Baylor College of Medicine, Division of Transfusion Medicine and Coagulation, Texas Children’s Hospital, Houston, Texas, Texas Children’s Hospital, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, Division of Transfusion Medicine and Coagulation, Texas Children’s Hospital, Houston, Texas, Texas Children’s Hospital, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Division of Transfusion Medicine and Coagulation, Texas Children’s Hospital, Houston, Texas, Texas Children’s Hospital, Houston, Texas
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159
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Rimpiläinen R, Vakkala M, Rimpiläinen E, Jensen H, Rimpiläinen J, Erkinaro T, Kiviluoma K, Meriläinen S, Pokela M, Karttunen T, Juvonen T. Minimized and conventional cardiopulmonary bypass damage intestinal mucosal integrity. SCAND CARDIOVASC J 2011; 45:236-46. [PMID: 21495910 DOI: 10.3109/14017431.2011.572996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Previous studies have suggested that gastrointestinal integrity is compromised after cardiopulmonary bypass (CPB). We compared the effects of prolonged minimized (MCPB) and conventional CPB (CCPB) on intestinal mucosal integrity by determining mucosal damage, epithelial cell proliferation rate and distribution of tight junction proteins in a porcine model. DESIGN Fourteen animals were randomly assigned to undergo 240 minutes of mild hypothermic MCPB or CCPB. Ileal and colonic biopsies were obtained prior and at the end of CPB. Mucosal damage was determined under light microscopic evaluation. Immunohistochemistry was used to investigate epithelial expression of Ki-67 as a measure of cell proliferation rate and claudin-1, 2, 3, 4, 5, and 7 as elements of tight junctions. RESULTS In colonic biopsies, independent of the circuit type used, moderate mucosal damage was observed as indicated by focal epithelial damage, increased epithelial cell proliferation and decreased expression of tight junction protein claudin-4. CONCLUSIONS Colonic mucosal damage was observed similarly in MCPB and CCPB. Based on these results, the effects of MCPB on intestinal mucosal stability are similar to those of CCPB.
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160
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Beutel G, Wiesner O, Eder M, Hafer C, Schneider AS, Kielstein JT, Kühn C, Heim A, Ganzenmüller T, Kreipe HH, Haverich A, Tecklenburg A, Ganser A, Welte T, Hoeper MM. Virus-associated hemophagocytic syndrome as a major contributor to death in patients with 2009 influenza A (H1N1) infection. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R80. [PMID: 21366922 PMCID: PMC3219333 DOI: 10.1186/cc10073] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 02/08/2011] [Accepted: 03/02/2011] [Indexed: 02/06/2023]
Abstract
Introduction Virus-associated hemophagocytic syndrome (VAHS) is a severe complication of various viral infections often resulting in multiorgan failure and death. The purpose of this study was to describe baseline characteristics, development of VAHS, related treatments and associated mortality rate of consecutive critically ill patients with confirmed 2009 influenza A (H1N1) infection and respiratory failure. Methods We conducted a prospective observational study of 25 critically ill patients with 2009 influenza A (H1N1) infection at a single-center intensive care unit in Germany between 5 October 2009 and 4 January 2010. Demographic data, comorbidities, diagnosis of VAHS, illness progression, treatments and survival data were collected. The primary outcome measure was the development of VAHS and related mortality. Secondary outcome variables included duration of mechanical ventilation, support of extracorporeal membrane oxygenation and duration of viral shedding. Results VAHS developed in 9 (36%) of 25 critically ill patients with confirmed 2009 influenza A (H1N1) infection, and 8 (89%) of them died. In contrast, the mortality rate in the remaining 16 patients without VAHS was 25% (P = 0.004 for the survival difference in patients with or without VAHS by log-rank analysis). The patients were relatively young (median age, 45 years; interquartile range (IQR), 35 to 56 years of age); however, 18 patients (72%) presented with one or more risk factors for a severe course of illness. All 25 patients received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia, with a median duration of mechanical ventilation of 19 days (IQR, 13 to 26 days). An additional 17 patients (68%) required extracorporeal membrane oxygenation for a median of 10 days (IQR, 6 to 19 days). Conclusions The findings of this study raise the possibility that VAHS may be a frequent complication of severe 2009 influenza A (H1N1) infection and represents an important contributor to multiorgan failure and death.
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Affiliation(s)
- Gernot Beutel
- Departments of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany.
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161
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Kurundkar AR, Killingsworth CR, McIlwain RB, Timpa JG, Hartman YE, He D, Karnatak RK, Neel ML, Clancy JP, Anantharamaiah GM, Maheshwari A. Extracorporeal membrane oxygenation causes loss of intestinal epithelial barrier in the newborn piglet. Pediatr Res 2010; 68:128-33. [PMID: 20442689 PMCID: PMC2914515 DOI: 10.1203/pdr.0b013e3181e4c9f8] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an important life-support system used in neonates and young children with intractable cardiorespiratory failure. In this study, we used our porcine neonatal model of venoarterial ECMO to investigate whether ECMO causes gut barrier dysfunction. We subjected 3-wk-old previously healthy piglets to venoarterial ECMO for up to 8 h and evaluated gut mucosal permeability, bacterial translocation, plasma levels of bacterial products, and ultrastructural changes in gut epithelium. We also measured plasma lipopolysaccharide (LPS) levels in a small cohort of human neonates receiving ECMO. In our porcine model, ECMO caused a rapid increase in gut mucosal permeability within the first 2 h of treatment, leading to a 6- to 10-fold rise in circulating bacterial products. These changes in barrier function were associated with cytoskeletal condensation in epithelial cells, which was explained by phosphorylation of a myosin II regulatory light chain. In support of these findings, we also detected elevated plasma LPS levels in human neonates receiving ECMO, indicating a similar loss of gut barrier function in these infants. On the basis of these data, we conclude that ECMO is an independent cause of gut barrier dysfunction and bacterial translocation may be an important contributor to ECMO-related inflammation.
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Affiliation(s)
- Ashish R Kurundkar
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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