201
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Shuster C, Kanji H, Isac G, Jeovens R, Sidhu A, Kalan S, Yee J, Finlayson G. Seventy-seven days on veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from SARS-CoV-2. Perfusion 2023; 38:1311-1314. [PMID: 35653234 PMCID: PMC9519602 DOI: 10.1177/02676591221103545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Throughout the COVID-19 pandemic veno-venous extracorporeal membrane oxygenation (VV ECMO) has emerged as a valid supportive intervention for severe COVID-19 pneumonia. In this report we describe the use of prolonged ECMO (77 days) to support a patient with COVID-19, ultimately resulting in lung recovery and discharge home. This report also emphasizes the value of physiotherapy in patients on ECMO and the importance of collaboration between ECMO programs and lung transplant teams in the care of these patients.
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Affiliation(s)
- Constantin Shuster
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hussein Kanji
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - George Isac
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Roxanne Jeovens
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Amandeep Sidhu
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Simmie Kalan
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Yee
- Division of Thoracic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Gordon Finlayson
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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202
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Zheng P, Wang X, Guo T, Gao W, Huang Q, Yang J, Gao H, Liu Q. Cardiac troponin as a prognosticator of mortality in patients with sepsis: A systematic review and meta-analysis. Immun Inflamm Dis 2023; 11:e1014. [PMID: 37773717 PMCID: PMC10515504 DOI: 10.1002/iid3.1014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND The impact of cardiac troponin on the short-term and long-term prognosis of patients with sepsis remains uncertain. Therefore, we conducted a meta-analysis to investigate the role of cardiac troponin as a potential indicator for sepsis mortality. METHODS We performed a comprehensive search for articles published before November 2022 using Google Scholar, PubMed, and Web of Science. Inclusion criteria for the studies were: (1) investigation of cardiac troponin, and (2) investigation of sepsis. Exclusion criteria included: (1) inability to obtain or calculate hazard ratio (HR) and 95% confidence interval (CI) for the relationship between cardiac troponin level and sepsis mortality, and (2) reviews, meta-analyses, and case reports. Analysis of HRs and 95% CIs for the association between cardiac troponin level and sepsis mortality was conducted using STATA 12.0 software. RESULTS Our study included 24 prospective studies (comprising 20,457 sepsis patients) and 4 retrospective studies (comprising 1416 sepsis patients). Meta-analysis demonstrated that elevated cardiac troponin levels were significantly associated with increased sepsis mortality using a random effects model (HR = 1.57, 95% CI 1.41-1.75). Moreover, elevated cardiac troponin levels were also significantly associated with increased hospital mortality of sepsis (HR = 1.35, 95% CI 1.19-1.53) and long-term mortality of sepsis (HR = 1.96, 95% CI 1.51-2.55) using the random effects model. CONCLUSIONS Overall, our finding revealed that elevated cardiac troponin for sepsis patients was a predictor of hospital and long-term mortality. Clinicians may treat septic patients with elevated cardiac troponin more cautious to avoid extra death. Moreover, large clinical studies are warranted to validate this association.
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Affiliation(s)
- Peiqiu Zheng
- Department of EmergencyLiyang Hospital of Chinese MedicineChangzhouJiangsuChina
| | - Xing Wang
- Department of Critical Care MedicineAffiliated Hospital of Nanjing University of Chinese MedicineNanjingJiangsuChina
| | - Tao Guo
- Department of EmergencyAffiliated Hospital of Nanjing University of Chinese MedicineNanjingJiangsuChina
| | - Wei Gao
- Department of Critical Care MedicineJiangsu Province Hospital on Integration of Chinese and Western MedicineNanjingJiangsuChina
| | - Qiang Huang
- Department of EmergencyLiyang Hospital of Chinese MedicineChangzhouJiangsuChina
| | - Jie Yang
- Department of Critical Care MedicineLiyang Hospital of Chinese MedicinChangzhouJiangsuChina
| | - Hui Gao
- Department of Critical Care MedicineLiyang Hospital of Chinese MedicinChangzhouJiangsuChina
| | - Qian Liu
- Department of Critical Care MedicineLiyang Hospital of Chinese MedicinChangzhouJiangsuChina
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203
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Tan C, Hota SS, Fan E, Marquis K, Vicencio E, Vaisman A. Bloodstream infection and ventilator-associated pneumonia in patients with coronavirus disease 2019 (COVID-19) supported by extracorporeal membrane oxygenation. Infect Control Hosp Epidemiol 2023; 44:1443-1450. [PMID: 36451285 PMCID: PMC10507515 DOI: 10.1017/ice.2022.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has been widely used in the care of patients with respiratory failure from coronavirus disease 2019 (COVID-19). We characterized bloodstream infections (BSIs) and ventilator-associated pneumonias (VAPs) in COVID-19 patients supported with ECMO, and we investigated their impact on patient outcomes. DESIGN Retrospective cohort study from March 1, 2020, to June 30, 2021. SETTING Academic tertiary-care referral center. PATIENTS Consecutive adult patients admitted for COVID-19 who received ECMO. METHODS We identified BSIs and VAPs and described their epidemiology and microbiology. Cumulative antimicrobial use and the specific management of BSIs were determined. Multivariate time-dependent Cox proportional hazards models were constructed to evaluate the impact of BSIs and VAPs on mortality, controlling for age, receipt of COVID-19-specific therapeutics, and new renal replacement therapy. RESULTS We identified 136 patients who received ECMO for COVID-19 pneumonia during the study period. BSIs and VAPs occurred in 81 patients (59.6%) and 93 patients (68.4%), respectively. The incidence of BSIs was 29.5 per 1,000 ECMO days and increased with duration of ECMO cannulation. Enterococci, Enterobacterales, and Staphylococcus aureus were the most common causes of BSIs, whereas S. aureus, Klebsiella species, and Pseudomonas aeruginosa comprised the majority of VAPs. Mean antibiotic use comprised 1,031 days of therapy per 1,000 ECMO days (SD, 496). We did not detect an association between BSIs or VAPs and mortality. CONCLUSIONS BSIs and VAPs are common in COVID-19 ECMO-supported patients. Efforts to optimize their diagnosis, prevention, and management should be prioritized.
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Affiliation(s)
- Charlie Tan
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Susy S. Hota
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Krista Marquis
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Elisa Vicencio
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Alon Vaisman
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
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204
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Gasch-Illescas A, Andrade-Arroyo M, Vallejo-Vaz AJ, Praena-Fernández JM, Guerrero JA, Calderón EJ, Pollán M, Medrano FJ. The Impact of the Second Wave of the COVID-19 Pandemic on Non-COVID Hospital Care in a Tertiary Hospital in Spain. J Clin Med 2023; 12:5507. [PMID: 37685572 PMCID: PMC10487824 DOI: 10.3390/jcm12175507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
In 2020, Spain ranked fourth among European countries with the highest excess mortality due to COVID-19 disease. This study evaluates the impact of the COVID-19 pandemic on non-COVID patients in a tertiary hospital during the second pandemic wave in Spain (22 June 2020-6 December 2020). Data from Virgen del Rocío University Hospital in Seville during that timeframe were compared with the data from the same period in the preceding two years (2018-2019). Between-group comparisons were performed using the Chi-squared test, Student's t-test, or Mann-Whitney U tests, as appropriate. A total of 63,137 non-COVID patients were included in this study. During the second pandemic wave, a 19% decrease was observed in the annual number of non-COVID admissions overall (18,260 vs. 22,439, p < 0.001), but a 10% increase in the proportion of emergency admissions (60.6% vs. 54.93%, p < 0.001), a higher severity level of patients (1.79 vs. 1.72, p < 0.001), a longer in-hospital stay (7.02 vs. 6.74 days, p < 0.001), a 26% increase in non-COVID mortality (4.9% vs. 3.9%, p < 0.001), and a 50% increase in global mortality (5.9 vs. 3.9, p < 0.001) were also observed. In terms of both medical and surgical diagnoses, a significant reduction in the number of admissions and an increase in in-hospital mortality were observed. These results demonstrate the significant impact of the pandemic on hospital care, similar to what was previously observed during the initial wave in the same hospital. Our findings emphasize the need to include non-COVID patients when assessing the broad impact of the pandemic on healthcare, beyond its direct effects on COVID-19 patients.
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Affiliation(s)
- Antonia Gasch-Illescas
- Service de Santé Étudiants, Campus Arras, University of Artois, 62000 Arras, France;
- Escuela Internacional de Doctorado, University of Seville, 41004 Seville, Spain
- Infectious and Immune System Diseases, Epidemiology and Public Health, Instituto de Biomedicina de Sevilla, IBIS, Hospital Universitario Virgen del Rocío, CSIC, University of Seville, 41013 Seville, Spain
| | - María Andrade-Arroyo
- Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain;
| | - Antonio J. Vallejo-Vaz
- Department of Medicine, Faculty of Medicine, University of Seville, 41013 Seville, Spain;
- Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBIS, Hospital Universitario Virgen del Rocío, Consejo Superior de Investigaciones Científicas, CSIC, University of Seville, 41013 Seville, Spain;
| | | | - José A. Guerrero
- Servicio de Documentación Clínica, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| | - Enrique J. Calderón
- Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBIS, Hospital Universitario Virgen del Rocío, Consejo Superior de Investigaciones Científicas, CSIC, University of Seville, 41013 Seville, Spain;
- Instituto de Biomedicina de Sevilla, IBIS, HUVR, Junta de Andalucía, Consejo Superior de Investigaciones Científicas, CSIC, University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, 28029 Madrid, Spain;
| | - Marina Pollán
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- National Center for Epidemiology, Instituto de Salud Carlos III ES, 28029 Madrid, Spain
| | - Francisco J. Medrano
- Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla, IBIS, Hospital Universitario Virgen del Rocío, Consejo Superior de Investigaciones Científicas, CSIC, University of Seville, 41013 Seville, Spain;
- Instituto de Biomedicina de Sevilla, IBIS, HUVR, Junta de Andalucía, Consejo Superior de Investigaciones Científicas, CSIC, University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, 28029 Madrid, Spain;
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205
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Mihu MR, Maybauer MO, Cain K, Swant LV, Harper MD, Schoaps RS, Brewer JM, Sharif A, Benson C, El Banayosy AM, El Banayosy A. Bridging the gap: safety and outcomes of intensivist-led ECMO retrievals. Front Med (Lausanne) 2023; 10:1239006. [PMID: 37680617 PMCID: PMC10481738 DOI: 10.3389/fmed.2023.1239006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023] Open
Abstract
Purpose Most extracorporeal membrane oxygenation (ECMO) cannulations are performed by cardiothoracic surgeons (CTS). Due to an increase in utilization of ECMO and limited availability of CTS, there is a mismatch between ECMO demand and CTS accessibility for remote cannulations. We report our intensivist-led program's experience in remote ECMO cannulations, retrievals, complications, and outcomes. Materials and methods A prospective, single-center, observational study was performed on patients that required ECMO cannulation at the referring facilities and were transported to our institution between program initiation, on October 1, 2014 to September 30, 2022. Results were presented as mean ± SD, median (min - max) or number (%). Results Since program commencement, 305 patients were accepted for ECMO retrieval. Three hundred and three patients were placed on ECMO at the 47 referring hospitals among 5 states. In our study, 185 (61%) patients required veno-arterial ECMO and 115 (38%) were placed on veno-venous ECMO. Three patients (1%) were cannulated for veno-arteriovenous ECMO. Twenty patients were cannulated under cardio-pulmonary resuscitation. Most of the patients were transported by ambulance (79%), 14% by helicopter, and 7% by airplane. Six out of the 303 patients did not leave the referring facility. All patients that left the referring hospitals arrived safely to our institution. No major complications occurred in route. Conclusion Our study's findings indicate that non-CTS physicians can successfully cannulate and retrieve patients with a low complication profile.
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Affiliation(s)
- Mircea R. Mihu
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
- Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, OK, United States
| | - Marc O. Maybauer
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, QLD, Australia
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, FL, United States
- Department of Anesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
| | - Kaitlyn Cain
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Laura V. Swant
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Michael D. Harper
- MedStar Heart and Vascular Institute, MedStar Washington Medical Center, Washington, DC, United States
| | - Robert S. Schoaps
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Joseph M. Brewer
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Ammar Sharif
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Clayne Benson
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Ahmed M. El Banayosy
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
| | - Aly El Banayosy
- Specialty Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, United States
- Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, OK, United States
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206
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Tiruvoipati R, Ludski J, Gupta S, Subramaniam A, Ponnapa Reddy M, Paul E, Haji K. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+ device. Eur J Med Res 2023; 28:291. [PMID: 37596670 PMCID: PMC10436516 DOI: 10.1186/s40001-023-01269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Several extracorporeal carbon dioxide removal (ECCO2R) devices are currently in use with variable efficacy and safety profiles. PrismaLung+ is an ECCO2R device that was recently introduced into clinical practice. It is a minimally invasive, low flow device that provides partial respiratory support with or without renal replacement therapy. Our aim was to describe the clinical characteristics, efficacy, and safety of PrismaLung+ in patients with acute hypercapnic respiratory failure. METHODS All adult patients who required ECCO2R with PrismaLung+ for hypercapnic respiratory failure in our intensive care unit (ICU) during a 6-month period between March and September 2022 were included. RESULTS Ten patients were included. The median age was 55.5 (IQR 41-68) years, with 8 (80%) male patients. Six patients had acute respiratory distress syndrome (ARDS), and two patients each had exacerbations of asthma and chronic obstructive pulmonary disease (COPD). All patients were receiving invasive mechanical ventilation at the time of initiation of ECCO2R. The median duration of ECCO2R was 71 h (IQR 57-219). A significant improvement in pH and PaCO2 was noted within 30 min of initiation of ECCO2R. Nine patients (90%) survived to weaning of ECCO2R, eight (80%) survived to ICU discharge and seven (70%) survived to hospital discharge. The median duration of ICU and hospital stays were 14.5 (IQR 8-30) and 17 (IQR 11-38) days, respectively. There were no patient-related complications with the use of ECCO2R. A total of 18 circuits were used in ten patients (median 2 per patient; IQR 1-2). Circuit thrombosis was noted in five circuits (28%) prior to reaching the expected circuit life with no adverse clinical consequences. CONCLUSION(S) PrismaLung+ rapidly improved PaCO2 and pH with a good clinical safety profile. Circuit thrombosis was the only complication. This data provides insight into the safety and efficacy of PrismaLung+ that could be useful for centres aspiring to introduce ECCO2R into their clinical practice.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia.
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Jarryd Ludski
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care Medicine, Dandenong Hospital, Dandenong, Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Intensive Care, Calvary Hospital, Canberra, ACT, Australia
| | - Eldho Paul
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Alfred Hospital, Melbourne, VIC, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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207
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Jung B, Huguet H, Molinari N, Jaber S. Sodium bicarbonate for the treatment of severe metabolic acidosis with moderate or severe acute kidney injury in the critically ill: protocol for a randomised clinical trial (BICARICU-2). BMJ Open 2023; 13:e073487. [PMID: 37591655 PMCID: PMC10441043 DOI: 10.1136/bmjopen-2023-073487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/21/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION When both severe metabolic acidemia (pH equal or less than 7.20; PaCO2 equal or less than 45 mm Hg and bicarbonate concentration equal or less than of 20 mmol/L) and moderate-to-severe acute kidney injury are observed, day 28 mortality is approximately 55%-60%. A multiple centre randomised clinical trial (BICARICU-1) has suggested that sodium bicarbonate infusion titrated to maintain the pH equal or more than 7.30 is associated with a higher survival rate (secondary endpoint) in a prespecified stratum of patients with both severe metabolic acidemia and acute kidney injury patients. Whether sodium bicarbonate infusion may improve survival at day 90 (primary outcome) in these severe acute kidney injury patients is currently unknown. METHODS AND ANALYSIS The sodium bicarbonate for the treatment of severe metabolic acidosis with moderate or severe acute kidney injury in the critically ill: a randomised clinical trial (BICARICU-2) trial is an investigator-initiated, multiple centre, stratified, parallel-group, unblinded trial with a computer-generated allocation sequence and an electronic system-based randomisation. After randomisation, the intervention group will receive 4.2% sodium bicarbonate infusion to target a plasma pH equal or more than 7.30 while the control group will not receive sodium bicarbonate. The primary outcome is the day 90 mortality. Main secondary outcomes are organ support dependences. ETHICS AND DISSEMINATION The trial has been approved by the appropriate ethics committee (CPP Nord Ouest, Rouen, France, 25 April 2019, number: 19.03.15.72446). Informed consent is required. If sodium bicarbonate improves day 90 mortality, it will become part of the routine care. TRIAL REGISTRATION NUMBER NCT04010630.
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Affiliation(s)
- Boris Jung
- Department of Medical Intensive Care, Montpellier University Hospital, Montpellier, France
- PhyMedExp Laboratory, University of Montpellier, Montpellier, France
| | - Helena Huguet
- Department of Statistics, Montpellier Université d'Excellence, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, Montpellier Université d'Excellence, Montpellier, France
| | - Samir Jaber
- PhyMedExp Laboratory, University of Montpellier, Montpellier, France
- Saint Eloi Department of Anesthesiology and Critical Care Medicine, Montpellier University Hospital, Montpellier, France
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208
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Lüthi-Corridori G, Boesing M, Ottensarendt N, Leuppi-Taegtmeyer AB, Schuetz P, Leuppi JD. Predictors of Length of Stay, Mortality and Rehospitalization in COPD Patients: A Retrospective Cohort Study. J Clin Med 2023; 12:5322. [PMID: 37629364 PMCID: PMC10455093 DOI: 10.3390/jcm12165322] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/03/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic lung disease that has a significant impact on individuals and healthcare systems worldwide. This study aimed to identify factors that predict the length of a hospital stay (LOHS), one-year mortality, and rehospitalization within 6 months in patients admitted for acute exacerbation of COPD (AECOPD). A retrospective cohort study was conducted using data from 170 patients admitted to a district general hospital in Switzerland between January 2019 and February 2020. Sociodemographic and health-related variables measured at admission were analyzed as potential predictors. Multivariable zero-truncated negative binomial and logistic regression analyses were performed to assess the risk factors for LOHS (primary endpoint), mortality, and rehospitalization. The results show that an indication for oxygen supplementation was the only significant predictor of LOHS. In the logistic regression analysis, older age, COPD severity stages GOLD III and IV, active cancer and arrhythmias were associated with higher mortality, whereas rehabilitation after discharge was associated with lower mortality. There were no significant associations regarding rehospitalization. This study identified routinely available predictors for LOHS and mortality, which may further advance our understanding of AECOPD and thereby improve patient management, discharge planning, and hospital costs. The protective effect of rehabilitation after hospitalization regarding lower mortality warrants further confirmation and may improve the comprehensive management of patients with AECOPD.
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Affiliation(s)
- Giorgia Lüthi-Corridori
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Maria Boesing
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Nicola Ottensarendt
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Anne Barbara Leuppi-Taegtmeyer
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
- Department of Patient Safety, Medical Directorate, University Hospital Basel, 4056 Basel, Switzerland
| | - Philipp Schuetz
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
- Cantonal Hospital Aarau, University Department of Medicine, 5001 Aarau, Switzerland
| | - Joerg Daniel Leuppi
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
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209
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Orthmann T, Ltaief Z, Bonnemain J, Kirsch M, Piquilloud L, Liaudet L. Retrospective analysis of factors associated with outcome in veno-venous extra-corporeal membrane oxygenation. BMC Pulm Med 2023; 23:301. [PMID: 37587413 PMCID: PMC10429070 DOI: 10.1186/s12890-023-02591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND The outcome of Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) in acute respiratory failure may be influenced by patient-related factors, center expertise and modalities of mechanical ventilation (MV) during ECMO. We determined, in a medium-size ECMO center in Switzerland, possible factors associated with mortality during VV-ECMO for acute respiratory failure of various etiologies. METHODS We retrospectively analyzed all patients treated with VV-ECMO in our University Hospital from 2012 to 2019 (pre-COVID era). Demographic variables, severity scores, MV duration before ECMO, pre and on-ECMO arterial blood gases and respiratory variables were collected. The primary outcome was ICU mortality. Data were compared between survivors and non-survivors, and factors associated with mortality were assessed in univariate and multivariate analyses. RESULTS Fifty-one patients (33 ARDS, 18 non-ARDS) were included. ICU survival was 49% (ARDS, 39%; non-ARDS 67%). In univariate analyses, a higher driving pressure (DP) at 24h and 48h on ECMO (whole population), longer MV duration before ECMO and higher DP at 24h on ECMO (ARDS patients), were associated with mortality. In multivariate analyses, ECMO indication, higher DP at 24h on ECMO and, in ARDS, longer MV duration before ECMO, were independently associated with mortality. CONCLUSIONS DP on ECMO and longer MV duration before ECMO (in ARDS) are major, and potentially modifiable, factors influencing outcome during VV-ECMO.
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Affiliation(s)
- Thomas Orthmann
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland
| | - Zied Ltaief
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
| | - Jean Bonnemain
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
| | - Matthias Kirsch
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland
- The Department of Cardiac Surgery, University Hospital Medical Center, Lausanne, 1011, Switzerland
| | - Lise Piquilloud
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland
| | - Lucas Liaudet
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland.
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland.
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210
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Burša F, Frelich M, Sklienka P, Jor O, Máca J. Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure. J Clin Med 2023; 12:5196. [PMID: 37629239 PMCID: PMC10455442 DOI: 10.3390/jcm12165196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.
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Affiliation(s)
- Filip Burša
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Michal Frelich
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Peter Sklienka
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Jan Máca
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
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211
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Brown MR, Boster JM, Goertzen SM, Morris MJ, Manninen ES. Enterococcus faecium Empyema Following Extracorporeal Membrane Oxygenation for COVID-19 Acute Respiratory Distress Syndrome. Cureus 2023; 15:e42789. [PMID: 37664261 PMCID: PMC10469799 DOI: 10.7759/cureus.42789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
A 33-year-old male with severe COVID-19 required prolonged veno-venous extracorporeal membrane oxygenation (ECMO) support. Following decannulation, he developed an Enterococcus faecium empyema. Tube thoracostomy and broad-spectrum antibiotics were initiated, followed by an unsuccessful attempt at pleural irrigation with saline, given the patient had an increased risk of bleeding due to the concomitant requirement for systemic anticoagulation. Subsequently, intrapleural tissue plasminogen activator (tPA) and recombinant human Dornase alfa (DNase) were safely administered with the resolution of empyema. Enterococcus faecium is an uncommon cause of pleural empyema and, to our knowledge, has not previously been reported to be associated with COVID-19 or ECMO.
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Affiliation(s)
- Mark R Brown
- Internal Medicine, San Antonio Military Medical Center, San Antonio, USA
| | - Joshua M Boster
- Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, San Antonio, USA
| | - Stephen M Goertzen
- Pulmonary and Critical Care, San Antonio Military Medical Center, San Antonio, USA
| | - Michael J Morris
- Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, San Antonio, USA
| | - Erik S Manninen
- Critical Care Medicine, San Antonio Military Medical Center, San Antonio, USA
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212
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Mostafa AMHAM, Tuttle CJ, Mckie MA, Fowles JA, Parmar J, Vuylsteke A. Predictors of health-related quality of life in patients undergoing extracorporeal membrane oxygenation for acute severe respiratory failure. J Intensive Care Soc 2023; 24:283-291. [PMID: 37744072 PMCID: PMC10515334 DOI: 10.1177/17511437221111639] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a form of life support used in severe respiratory failure. While the short-term complications of VV-ECMO are well described, impacts on health-related quality of life (HRQOL) are less well characterised. This study aims to assess the HRQOL of patients who underwent VV-ECMO for acute severe respiratory failure and explore predictors of poor HRQOL. Methods We performed a retrospective, observational study of a large cohort of adults who underwent VV-ECMO for acute severe respiratory failure in a single tertiary centre (June 2013-March 2019). Patients surviving critical care discharge were invited to a six-month clinic, where they completed an EQ-5D-5L questionnaire assessing HRQOL. Multivariate analysis was performed to assess prognostic factors for HRQOL. Results Among the 245 consecutive patients included in this study (median age 45 years), 187 (76.3%) survived until ECMO decannulation and 172 (70.2%) until hospital discharge. Of those, 98 (57.3%) attended a follow-up clinic at a mean (±SD) of 204 (±45) days post-discharge. Patients reported problems with pain/discomfort (56%), usual daily activities (53%), anxiety/depression (49%), mobility (46%), and personal care (21%). Multivariate analysis identified limb ischaemia (-0.266, 95% C.I. [-0.116; -0.415], p = 0.0005), renal replacement therapy (-0.149, [-0.046; -0.252], p = 0.0044), and having received more than four platelet units (-0.157, [-0.031; -0.283], p = 0.0146) as predictors of poor HRQOL. Conclusion We report that survivors of VV-ECMO have reduced HRQOL in multiple domains at 6 months, with pain reported most frequently. Patients who had limb ischaemia, renal replacement therapy or were transfused more than four units of platelets are particularly at risk of poor HRQOL and may benefit from added support measures.
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Affiliation(s)
| | | | - Mikel A Mckie
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Jo-Anne Fowles
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jasvir Parmar
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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213
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Ismail KB, Essafi F, Talik I, Slimene NB, Sdiri I, Dhia BB, Merhbene T. Awake prone positioning for COVID-19 acute hypoxemic respiratory failure in Tunisia. Acute Crit Care 2023; 38:271-277. [PMID: 37652857 PMCID: PMC10497894 DOI: 10.4266/acc.2023.00591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND In this study, we explored whether awake prone position (PP) can impact prognosis of severe hypoxemia coronavirus disease 2019 (COVID-19) patients. METHODS This was a prospective observational study of severe, critically ill adult COVID-19 patients admitted to the intensive care unit. Patients were divided into two groups: group G1, patients who benefited from a vigilant and effective PP (>4 hours minimum/24) and group G2, control group. We compared demographic, clinical, paraclinical and evolutionary data. RESULTS Three hundred forty-nine patients were hospitalized during the study period, 273 met the inclusion criteria. PP was performed in 192 patients (70.3%). The two groups were comparable in terms of demographic characteristics, clinical severity and modalities of oxygenation at intensive care unit (ICU) admission. The mean PaO2/ FIO2 ratios were 141 and 128 mm Hg, respectively (P=0.07). The computed tomography scan was comparable with a critical >75% in 48.5% (G1) versus 54.2% (G2). The median duration of the daily PP session was 13±7 hours per day. The average duration of spontaneous PP days was 7 days (4-19). Use of invasive ventilation was lower in the G1 group (27% vs. 56%, P=0.002). Healthcare-associated infections were significantly lower in G1 (42.1% vs. 82%, P=0.01). Duration of total mechanical ventilation and length of ICU stay were comparable between the two groups. Mortality was significantly higher in G2 (64% vs. 28%, P=0.02). CONCLUSIONS Our study confirmed that awake PP can improve prognosis in COVID-19 patients. Randomized controlled trials are needed to confirm this result.
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Affiliation(s)
- Khaoula Ben Ismail
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
- Research Unit for Respiratory Failure and Mechanical Ventilation UR22SP01, Abderrahmen Mami Hospital, Ministry of Higher Education and Scientific Research, Ariana, Tunisia
| | - Fatma Essafi
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
- Research Unit for Respiratory Failure and Mechanical Ventilation UR22SP01, Abderrahmen Mami Hospital, Ministry of Higher Education and Scientific Research, Ariana, Tunisia
| | - Imen Talik
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
| | - Najla Ben Slimene
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
- Research Unit for Respiratory Failure and Mechanical Ventilation UR22SP01, Abderrahmen Mami Hospital, Ministry of Higher Education and Scientific Research, Ariana, Tunisia
| | - Ines Sdiri
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
| | - Boudour Ben Dhia
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
| | - Takoua Merhbene
- Medical Intensive Care Unit, Regional Hospital of Zaghouan and Faculty of Medicine of Tunis, University of Tunis El Manar, Zaghouan, Tunisia
- Research Unit for Respiratory Failure and Mechanical Ventilation UR22SP01, Abderrahmen Mami Hospital, Ministry of Higher Education and Scientific Research, Ariana, Tunisia
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214
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Ahn YH, Lee HY, Lee SM, Lee J. Factors influencing sleep quality in the intensive care unit: a descriptive pilot study in Korea. Acute Crit Care 2023; 38:278-285. [PMID: 37562953 PMCID: PMC10497899 DOI: 10.4266/acc.2023.00514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/02/2023] [Accepted: 05/14/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND As sleep disturbances are common in the intensive care unit (ICU), this study assessed the sleep quality in the ICU and identified barriers to sleep. METHODS Patients admitted to the ICUs of a tertiary hospital between June 2022 and December 2022 who were not mechanically ventilated at enrollment were included. The quality of sleep (QoS) at home was assessed on a visual analog scale as part of an eight-item survey, while the QoS in the ICU was evaluated using the Korean version of the Richards-Campbell Sleep Questionnaire (K-RCSQ). Good QoS was defined by a score of ≥50. RESULTS Of the 30 patients in the study, 19 reported a QoS score <50. The Spearman correlation coefficient showed no meaningful relationship between the QoS at home and the overall K-RCSQ QoS score in the ICU (r=0.16, P=0.40). The most common barriers to sleep were physical discomfort (43%), being awoken for procedures (43%), and feeling unwell (37%); environmental factors including noise (30%) and light (13%) were also identified sources of sleep disruption. Physical discomfort (median [interquartile range]: 32 [28.0-38.0] vs. 69 [42.0-80.0], P=0.004), being awoken for procedures (36 [20.0-48.0] vs. 54 [36.0-80.0], P=0.04), and feeling unwell (31 [18.0-42.0] vs. 54 [40.0-76.0], P=0.01) were associated with lower K-RCSQ scores. CONCLUSIONS In the ICU, physical discomfort, patient care interactions, and feeling unwell were identified as barriers to sleep.
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Affiliation(s)
- Yoon Hae Ahn
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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215
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Sanivarapu RR, Osman U, Latha Kumar A. A Systematic Review of Mortality Rates Among Adult Acute Respiratory Distress Syndrome Patients Undergoing Extracorporeal Membrane Oxygenation Therapy. Cureus 2023; 15:e43590. [PMID: 37719572 PMCID: PMC10503872 DOI: 10.7759/cureus.43590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a severe lung disease associated with a high mortality rate. Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe ARDS patients who do not respond to conventional treatments. Nevertheless, the optimal management of ARDS patients undergoing ECMO and their mortality rates remain subjects of controversy. Thus, this systematic review aims to assess mortality rates in ARDS patients on ECMO and identify associated factors. The review adhered to the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) 2020 guidelines. A comprehensive literature search was conducted on PubMed, PubMed Central (PMC), Medline, and Embase. In accordance with our inclusion and exclusion criteria, filters, and key terms, we proceeded to screen the articles. After assessing the relevance of each article to our topic, further screening was carried out. Quality assessment of the articles was conducted, resulting in the inclusion of a total of 12 articles for the review. The primary outcome focused on mortality rates among ARDS patients undergoing ECMO. Secondary outcomes explored potential contributors to mortality, including patient age, underlying cause of ARDS, and Sequential Organ Failure Assessment (SOFA) scores at the initiation of ECMO. Mortality rates exhibited significant variation, ranging from 22% to 62.6%. Several factors emerged as potential predictors of mortality, encompassing patient age, comorbidities, complications during ECMO therapy, and treatment-related variables. This systematic review offers valuable insights into the intricate factors influencing mortality rates among ARDS patients on ECMO. A comprehension of these factors is essential to steer clinical practice and enhance patient outcomes. While ECMO serves as a restorative avenue for ARDS patients, future research is warranted to further elucidate these complex interactions and refine ECMO therapy protocols.
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Affiliation(s)
- Raghavendra R Sanivarapu
- Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Usama Osman
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Geriatrics, Michigan State University College of Human Medicine, East Lansing, USA
| | - Abishek Latha Kumar
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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216
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Whitmore SP, Cyr KJ, Cohen ES, Schlauch DJ, Gidwani HV, Sterling RK, Castiglia RP, Stell OT, Jarzembowski JL, Kunavarapu CR, McRae AT, Dellavolpe JD. Extracorporeal Membrane Oxygenation for Acute Respiratory Failure Due to COVID-19: A Multicenter Matched Cohort Study. ASAIO J 2023; 69:734-741. [PMID: 37531086 PMCID: PMC10627401 DOI: 10.1097/mat.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Mechanical ventilation for respiratory failure due to COVID-19 is associated with significant morbidity and mortality. Veno-venous extracorporeal membrane oxygenation (ECMO) is an attractive management option. This study sought to determine the effect of ECMO on hospital mortality and discharge condition in this population. We conducted a retrospective multicenter study to emulate a pragmatic targeted trial comparing ECMO to mechanical ventilation without ECMO for severe COVID-19. Data were gathered from a large hospital network database in the US. Adults admitted with COVID-19 were included if they were managed with ECMO or mechanical ventilation for severe hypoxemia and excluded if they had significant comorbidities or lacked functional independence on admission. The groups underwent coarsened exact matching on multiple clinical variables. The primary outcome was adjusted in-hospital mortality; secondary outcomes included ventilator days, intensive care days, and discharge destination. A total of 278 ECMO patients were matched to 2,054 comparison patients. Adjusted in-hospital mortality was significantly less in the ECMO group (38.8% vs. 60.1%, p < 0.001). Extracorporeal membrane oxygenation was associated with higher rates of liberation from mechanical ventilation, intensive care discharge, and favorable discharge destination. These findings support the use of ECMO for well-selected patients with severe acute respiratory failure due to COVID-19.
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Affiliation(s)
- Sage P. Whitmore
- From the Department of Critical Care Medicine, TriStar Centennial Medical Center, Nashville, Tennessee
| | | | - Elliott S. Cohen
- From the Department of Critical Care Medicine, TriStar Centennial Medical Center, Nashville, Tennessee
| | | | - Hitesh V. Gidwani
- Department of Critical Care Medicine, Methodist Hospital, San Antonio, Texas
| | - Rachel K. Sterling
- Department of Critical Care Medicine, Methodist Hospital, San Antonio, Texas
| | - Robert P. Castiglia
- From the Department of Critical Care Medicine, TriStar Centennial Medical Center, Nashville, Tennessee
| | - Owen T. Stell
- From the Department of Critical Care Medicine, TriStar Centennial Medical Center, Nashville, Tennessee
| | | | | | - Andrew T. McRae
- Department of Cardiology, TriStar Centennial Medical Center, Nashville, Tennessee
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Kwizera A, Kabatooro D, Atumanya P, Tumukunde J, Kalungi J, Mwanje AK, Obua D, Agaba P, Sendagire C, Nakibuuka J, Owachi D, Dünser MW, Alenyo-Ngabirano A, Olaro C, Kyobe-Bosa H, Kirenga BJ, Nakiyingi L, Kiwanuka N, Kateete DP, Joloba M, Sewankambo N, Summers C. Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study. Chest 2023; 164:369-380. [PMID: 36773933 PMCID: PMC9911971 DOI: 10.1016/j.chest.2023.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/19/2023] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. RESEARCH QUESTION Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? STUDY DESIGN AND METHODS A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. RESULTS Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n = 137; moderate, n = 247; and severe, n = 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3% (35.3%), 10% (9.4%), 11.6% (4.8%), 23.4% (14.4%), and 17.6% (36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8% of patients. Twenty-eight-day mortality was 51.9% (mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P < .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9% (P < .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5% vs 54%; P = .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95% CI, 0.98-0.99; P < .001) and respiratory rate (OR, 1.07; 95% CI, 1.03-1.12; P = .002) at admission and NIV (OR, 6.31; 95% CI, 2.29-17.37; P < .001) or IMV (OR, 8.08; 95% CI, 3.52-18.57; P < .001) use were independent risk factors for death. INTERPRETATION SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.
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Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Daphne Kabatooro
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Patience Atumanya
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joyce Kalungi
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Arthur Kavuma Mwanje
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Obua
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Agaba
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Cornelius Sendagire
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda; Uganda Heart Institute, Kampala, Uganda
| | - Jane Nakibuuka
- Department of Medicine and Intensive Care Unit, Mulago National Referral Hospital, Kampala, Uganda
| | | | - Martin W Dünser
- Department of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | | | | | - Henry Kyobe-Bosa
- Ministry of Health, Kampala, Uganda; Uganda Peoples Defence Forces, Kampala, Uganda; Kellogg College, University of Oxford, Oxford, England
| | - Bruce J Kirenga
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Makerere University Lung Institute, Kampala, Uganda
| | - Lydia Nakiyingi
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Noah Kiwanuka
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David Patrick Kateete
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses Joloba
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Nelson Sewankambo
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Mehta AB, Taylor JK, Day G, Lane TC, Douglas IS. Disparities in Adult Patient Selection for Extracorporeal Membrane Oxygenation in the United States: A Population-Level Study. Ann Am Thorac Soc 2023; 20:1166-1174. [PMID: 37021958 PMCID: PMC10405618 DOI: 10.1513/annalsats.202212-1029oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/05/2023] [Indexed: 04/07/2023] Open
Abstract
Rationale: Disparities in patient selection for advanced therapeutics in health care have been identified in multiple studies, but it is unclear if disparities exist in patient selection for extracorporeal membrane oxygenation (ECMO), a rapidly expanding critical care resource. Objectives: To determine if disparities exist in patient selection for ECMO based on sex, primary insurance, and median income of the patient's neighborhood. Methods: In a retrospective cohort study using the Nationwide Readmissions Database 2016-2019, we identified patients treated with mechanical ventilation (MV) and/or ECMO with billing codes. Patient sex, insurance, and income level for patients receiving ECMO were compared with the patients treated with MV only, and hierarchical logistic regression with the hospital as a random intercept was used to determine odds of receiving ECMO based on patient demographics. Results: We identified 2,170,752 MV hospitalizations with 18,725 cases of ECMO. Among patients treated with ECMO, 36.1% were female compared with 44.5% of patients treated with> MV only (adjusted odds ratio [aOR] for ECMO, 0.73; 95% confidence interval [CI], 0.70-0.75). Of patients treated with ECMO, 38.1% had private insurance compared with 17.4% of patients treated with MV only. Patients with Medicaid were less likely to receive ECMO than patients with private insurance (aOR, 0.55; 95% CI, 0.52-0.57). Patients treated with ECMO were more likely to live in the highest-income neighborhoods compared with patients treated with MV only (25.1% vs. 17.3%). Patients living in the lowest-income neighborhoods were less likely to receive ECMO than those living in the highest-income neighborhoods (aOR, 0.63; 95% CI, 0.60-0.67). Conclusions: Significant disparities exist in patient selection for ECMO. Female patients, patients with Medicaid, and patients living in the lowest-income neighborhoods are less likely to be treated with ECMO. Despite possible unmeasured confounding, these findings were robust to multiple sensitivity analyses. On the basis of previous work describing disparities in other areas of health care, we speculate that limited access in some neighborhoods, restrictive/biased interhospital transfer practices, differences in patient preferences, and implicit provider bias may contribute to the observed differences. Future studies with more granular data are needed to identify and modify drivers of observed disparities.
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Affiliation(s)
- Anuj B. Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Hospital Association, Denver, Colorado; and
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Jennifer K. Taylor
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Gwenyth Day
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor C. Lane
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Ivor S. Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Hospital Association, Denver, Colorado; and
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219
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Zhao W, Tiemuerniyazi X, Yang Z, Song Y, Feng W. Risk Prediction After Coronary Artery Bypass Grafting Combined With Coronary Endarterectomy. Am J Cardiol 2023; 200:153-159. [PMID: 37327670 DOI: 10.1016/j.amjcard.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 06/18/2023]
Abstract
Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) is used for complete revascularization of diffusely diseased coronary arteries. Nevertheless, studies reported an increased risk after this procedure. Therefore, risk prediction in these patients is essential. Patients who underwent CABG + CE during September 2008 and July 2022 at our center were retrospectively recruited. A total of 32 characteristics were analyzed. The least absolute shrinkage and selection operator regression were used for the feature selection, and multivariable Cox regression was applied to develop a nomogram for risk prediction. The primary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause death, nonfatal myocardial infarction, repeat revascularization, and stroke. A total of 570 patients with 601 CE targets, including left anterior descending (41.4%), right coronary artery (43.9%), left circumflex artery (6.8%), and diagonal branches/intermedius ramidus (8.0%), were enrolled. The mean age was 61.0 ± 8.9 years, and 77.7% were men. A total of 4 features were identified as the predictors of MACCE, including age ≥65 years (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.38 to 3.25, p <0.001), left main disease (HR 2.56, 95% CI 1.46 to 4.49, p = 0.001), mitral regurgitation (≥mild, HR 1.91, 95% CI 1.01 to 3.65, p = 0.049), and left anterior descending endarterectomy (HR 1.69, 95% CI 1.09 to 2.62, p = 0.018), and a nomogram for the 1- and 3-year MACCE prediction was developed. The model showed relatively good discrimination (C-index 0.68), calibration, and clinical usefulness. In conclusion, the nomogram provides estimation of the 1- and 3-year MACCE risk after CABG + CE.
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Affiliation(s)
- Wei Zhao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xieraili Tiemuerniyazi
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ziang Yang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangwu Song
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Feng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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220
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Garfield BE, Bianchi P, Arachchillage DJ, Caetano F, Desai S, Doyle J, Hernandez Caballero C, Doyle AM, Mehta S, Law A, Jaggar S, Kokosi M, Molyneaux PL, Passariello M, Naja M, Ridge C, Alçada J, Patel B, Singh S, Ledot S. A Comparison of Long-Term Outcomes in Patients Managed With Venovenous Extracorporeal Membrane Oxygenation in the First and Second Waves of the COVID-19 Pandemic in the United Kingdom. Crit Care Med 2023; 51:1064-1073. [PMID: 37276353 PMCID: PMC10335603 DOI: 10.1097/ccm.0000000000005864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Early studies of venovenous extracorporeal membrane oxygenation (ECMO) in COVID-19 have revealed similar outcomes to historical cohorts. Changes in the disease and treatments have led to differences in the patients supported on venovenous ECMO in the first and second waves. We aimed to compare these two groups in both the acute and follow-up phase. DESIGN Retrospective single-center cohort study comparing mortality at censoring date (November 30, 2021) and decannulation, patient characteristics, complications and lung function and quality of life (QOL-by European Quality of Life 5 Dimensions 3 Level Version) at first follow-up in patients supported on venovenous ECMO between wave 1 and wave 2 of the COVID-19 pandemic. SETTING Critical care department of a severe acute respiratory failure service. PATIENTS Patients supported on ECMO for COVID-19 between wave 1 (March 17, 2020, to August 31, 2020) and wave 2 (January 9, 2020, to May 25, 2021). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred twenty-three patients were included in our analysis. Survival at censoring date (χ 2 , 6.35; p = 0.012) and decannulation (90.4% vs 70.0%; p < 0.001) was significantly lower in the second wave, while duration of ECMO run was longer (12.0 d [18.0-30.0 d] vs 29.5 d [15.5-58.3 d]; p = 0.005). Wave 2 patients had longer application of noninvasive ventilation (NIV) prior to ECMO and a higher frequency of barotrauma. Patient age and NIV use were independently associated with increased mortality (odds ratio 1.07 [1.01-1.14]; p = 0.025 and 3.37 [1.12-12.60]; p = 0.043, respectively). QOL and lung function apart from transfer coefficient of carbon monoxide corrected for hemoglobin was similar at follow-up across the waves. CONCLUSIONS Most patients with COVID-19 supported on ECMO in both waves survived in the short and longer term. At follow-up patients had similar lung function and QOL across the two waves. This suggests that ECMO has an ongoing role in the management of a carefully selected group of patients with COVID-19.
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Affiliation(s)
- Benjamin E Garfield
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Paolo Bianchi
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Francisca Caetano
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Sujal Desai
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Radiology, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - James Doyle
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Clara Hernandez Caballero
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Anne-Marie Doyle
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Sachin Mehta
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Alexander Law
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sian Jaggar
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Department of Anaesthesia, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Maria Kokosi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Maurizio Passariello
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Meena Naja
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Carole Ridge
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Radiology, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Joana Alçada
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Brijesh Patel
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Suveer Singh
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephane Ledot
- Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Anaesthesia, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Radiology, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospitals, part of Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
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221
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Ko JP, Ng LS, Goh KJ, Chai HZ, Phua GC, Tan QL. Staff perception and attitudes towards a medical rapid response team with a multi-tiered response. Singapore Med J 2023; 64:527-533. [PMID: 34911185 PMCID: PMC10476913 DOI: 10.11622/smedj.2021223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joanna Phone Ko
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Lit Soo Ng
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Hui Zhong Chai
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Ghee Chee Phua
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Qiao Li Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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222
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Harlan EA, Mubarak E, Firn J, Goold SD, Shuman AG. Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study. J Gen Intern Med 2023; 38:2568-2576. [PMID: 37254008 PMCID: PMC10228431 DOI: 10.1007/s11606-023-08237-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/09/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce. OBJECTIVE To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making. DESIGN We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022. PARTICIPANTS Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling. APPROACH Semi-structured interviews were conducted with healthcare workers across Michigan. KEY RESULTS Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging. CONCLUSIONS A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.
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Affiliation(s)
- Emily A Harlan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
| | - Eman Mubarak
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Janice Firn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Susan D Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrew G Shuman
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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223
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Khan KS, Jawaid S, Memon UA, Perera T, Khan U, Farwa UE, Jindal U, Afzal MS, Razzaq W, Abdin ZU, Khawaja UA. Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions. Cureus 2023; 15:e43694. [PMID: 37724212 PMCID: PMC10505355 DOI: 10.7759/cureus.43694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.
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Affiliation(s)
- Khizar S Khan
- Basic Sciences, Foundation University Medical College, Islamabad, PAK
| | - Sanyah Jawaid
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Unaib Ahmed Memon
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Tharindu Perera
- General Medicine, Grodno State Medical University, Grodno, BLR
| | - Usman Khan
- General Practice, Akhtar Saeed Medical and Dental College, Lahore, PAK
| | - Umm E Farwa
- Emergency Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Urmi Jindal
- Internal Medicine, KJ Somaiya Medical College, Mumbai, IND
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
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224
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Ytrebø LM. Risk Factors for Stroke in COVID-19 Patients on Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1098-1100. [PMID: 37439645 DOI: 10.1097/ccm.0000000000005898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Lars Marius Ytrebø
- Department of Anesthesiology, University Hospital of North Norway, Tromsø, Norway
- Anesthesia and Critical Care Research Group, UIT-The Arctic University of Norway, Tromsø, Norway
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Fasanghari M, Keramat A. Investigating the effect of educational interventions on maternal competence: A systematic review and meta-analysis. J Educ Health Promot 2023; 12:254. [PMID: 37727416 PMCID: PMC10506766 DOI: 10.4103/jehp.jehp_25_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/05/2023] [Indexed: 09/21/2023]
Abstract
There have been many studies on maternal competence, but in the studies conducted in this field, different methods have been applied to educate mothers on maternal competence, which do not have a unified approach. This study aims to investigate the effect of educational interventions on maternal competence using a meta-analysis method. In this meta-analysis, a search was made in MEDLINE, CINAHL, PubMed, Scopus, Proquest, Google scholar, SID, and Magiran databases using Mesh and non-Mesh keywords between January 1992 and September 2022. The inclusion criteria included: Studies in which educational and counseling interventions on maternal competence have been investigated, studies that have used the Parenting Sense of Competence Scale (PSOC), RCT or interventional studies, participants who were primiparous women, articles that were published in English and Farsi, studies that reported sample size, mean and standard deviation of maternal competence scores in the intervention and control groups, and studies that scored at least 3 on the Jadad scale. Data were analyzed using Review Manager 5 (RevMan 5.3). In this meta-analysis and systematic review, finally, seven articles met the criteria for entering the research. The number of samples in the intervention group was 430 and in the control group was 429. The average maternal competence score with a 95% confidence interval was 3.51. This meta-analysis showed that educational interventions during pregnancy and after delivery could affect improving the competence of primiparous mothers. Education has increased the maternal competence score in the intervention group by 3.51 units compared to the control group.
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Affiliation(s)
- Maryam Fasanghari
- Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Afsaneh Keramat
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
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226
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Nedelea PL, Manolescu E, Ciumanghel AI, Constantin M, Hauta A, Sirbu O, Ionescu L, Blaj M, Corlade-Andrei M, Sorodoc V, Cimpoesu D. The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review. J Clin Med 2023; 12:4922. [PMID: 37568324 PMCID: PMC10419366 DOI: 10.3390/jcm12154922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/01/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).
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Affiliation(s)
- Paul Lucian Nedelea
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Emilian Manolescu
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Adi-Ionut Ciumanghel
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Anesthesia Intensive Care Unit, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandra Hauta
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Sirbu
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Lidia Ionescu
- 3rd Surgery Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Mihaela Blaj
- Anesthesia Intensive Care Unit, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | | | - Victorita Sorodoc
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Cimpoesu
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
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Sandrio S, Thiel M, Krebs J. The Outcome Relevance of Pre-ECMO Liver Impairment in Adults with Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:4860. [PMID: 37510975 PMCID: PMC10381435 DOI: 10.3390/jcm12144860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
We hypothesize that (1) a significant pre-ECMO liver impairment, which is evident in the presence of pre-ECMO acute liver injury and a higher pre-ECMO MELD (model for end-stage liver disease) score, is associated with increased mortality; and (2) the requirement of veno-veno-arterial (V-VA) ECMO support is linked to a higher prevalence of pre-ECMO acute liver injury, a higher pre-ECMO MELD score, and increased mortality. We analyze 187 ECMO runs (42 V-VA and 145 veno-venous (V-V) ECMO) between January 2017 and December 2020. The SAPS II score is calculated at ICU admission; hepatic function and MELD score are assessed at ECMO initiation (pre-ECMO) and during the first five days on ECMO. SOFA, PRESERVE and RESP scores are calculated at ECMO initiation. Pre-ECMO cardiac failure, acute liver injury, ECMO type, SAPS II and MELD, SOFA, PRESERVE, and RESP scores are associated with mortality. However, only the pre-ECMO MELD score independently predicts mortality (p = 0.04). In patients with a pre-ECMO MELD score > 16, V-VA ECMO is associated with a higher mortality risk (p = 0.0003). The requirement of V-VA ECMO is associated with the development of acute liver injury during ECMO support, a higher pre-ECMO MELD score, and increased mortality.
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Affiliation(s)
- Stany Sandrio
- Department of Anesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68165 Mannheim, Germany; (M.T.); (J.K.)
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228
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Kjellberg A, Douglas J, Hassler A, Al-Ezerjawi S, Boström E, Abdel-Halim L, Liwenborg L, Hetting E, Jonasdottir Njåstad AD, Kowalski J, Catrina SB, Rodriguez-Wallberg KA, Lindholm P. COVID-19-Induced Acute Respiratory Distress Syndrome Treated with Hyperbaric Oxygen: Interim Safety Report from a Randomized Clinical Trial (COVID-19-HBO). J Clin Med 2023; 12:4850. [PMID: 37510965 PMCID: PMC10381696 DOI: 10.3390/jcm12144850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/16/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND A few prospective trials and case series have suggested that hyperbaric oxygen therapy (HBOT) may be efficacious for the treatment of severe COVID-19, but safety is a concern for critically ill patients. We present an interim analysis of the safety of HBOT via a randomized controlled trial (COVID-19-HBO). METHODS A randomized controlled, open-label, clinical trial was conducted in compliance with good clinical practice to explore the safety and efficacy of HBOT for severe COVID-19 in critically ill patients with moderate acute respiratory distress syndrome (ARDS). Between 3 June 2020, and 17 May 2021, 31 patients with severe COVID-19 and moderate-to-severe ARDS, a ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) < 26.7 kPa (200 mmHg), and at least two defined risk factors for intensive care unit (ICU) admission and/or mortality were enrolled in the trial and randomized 1:1 to best practice, or HBOT in addition to best practice. The subjects allocated to HBOT received a maximum of five treatments at 2.4 atmospheres absolute (ATA) for 80 min over seven days. The subjects were followed up for 30 days. The safety endpoints were analyzed. RESULTS Adverse events (AEs) were common. Hypoxia was the most common adverse event reported. There was no statistically significant difference between the groups. Numerically, serious adverse events (SAEs) and barotrauma were more frequent in the control group, and the differences between groups were in favor of the HBOT in PaO2/FiO2 (PFI) and the national early warning score (NEWS); statistically, however, the differences were not significant at day 7, and no difference was observed for the total oxygen burden and cumulative pulmonary oxygen toxicity dose (CPTD). CONCLUSION HBOT appears to be safe as an intervention for critically ill patients with moderate-to-severe ARDS induced by COVID-19. CLINICAL TRIAL REGISTRATION NCT04327505 (31 March 2020) and EudraCT 2020-001349-37 (24 April 2020).
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Affiliation(s)
- Anders Kjellberg
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Perioperative Medicine and Intensive Care Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Johan Douglas
- Department of Anaesthesia and Intensive Care, Blekingesjukhuset, 371 85 Karlskrona, Sweden
| | - Adrian Hassler
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Sarah Al-Ezerjawi
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Emil Boström
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lina Abdel-Halim
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Lovisa Liwenborg
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Eric Hetting
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | | | | | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Academic Specialist Center, Center for Diabetes, 113 65 Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology and Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden
- Department of Reproductive Medicine, Division of Gynaecology and Reproduction, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Emergency Medicine, Division of Hyperbaric Medicine, University of California San Diego, La Jolla, CA 92093, USA
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229
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Abstract
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
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Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
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Basic D, Ní Chróinín D. In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system. BMC Geriatr 2023; 23:425. [PMID: 37434113 DOI: 10.1186/s12877-023-03947-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 03/31/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier. METHODS The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression. RESULTS A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001). CONCLUSIONS Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.
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Affiliation(s)
- David Basic
- Department of Geriatric Medicine, Liverpool Hospital, Locked Mail Bag 7103, Liverpool BC, NSW, 1871, Australia.
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, and South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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231
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Christensen DM, Strange JE, Falkentoft AC, El-Chouli M, Ravn PB, Ruwald AC, Fosbøl E, Køber L, Gislason G, Sehested TSG, Schou M. Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study. J Am Heart Assoc 2023:e030561. [PMID: 37421279 PMCID: PMC10382124 DOI: 10.1161/jaha.123.030561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/30/2023] [Indexed: 07/10/2023]
Abstract
Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.
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Affiliation(s)
| | - Jarl Emanuel Strange
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | | | | | - Pauline B Ravn
- Department of Cardiology Zealand University Hospital Roskilde Roskilde Denmark
| | | | - Emil Fosbøl
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Gunnar Gislason
- Danish Heart Foundation Copenhagen Denmark
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- The National Institute of Public Health University of Southern Denmark Copenhagen Denmark
| | - Thomas S G Sehested
- Danish Heart Foundation Copenhagen Denmark
- Department of Cardiology Zealand University Hospital Roskilde Roskilde Denmark
| | - Morten Schou
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
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Hol L, Schultz MJ, Martin-Loeches I, van Meenen DMP, Serpa Neto A, Paulus F. Differences in Ventilation Management and Outcomes between the Two First Waves of the COVID-19 Pandemic-A Comparison between Two Nationwide Observational Studies in The Netherlands. J Clin Med 2023; 12:4507. [PMID: 37445542 DOI: 10.3390/jcm12134507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/12/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
The aim of this analysis was to compare ventilation management and outcomes in invasively ventilated patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) between the first and second wave in the Netherlands. This is a post hoc analysis of two nationwide observational COVID-19 studies conducted in quick succession. The primary endpoint was ventilation management. Secondary endpoints were tracheostomy use, duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), and mortality. We used propensity score matching to control for observed confounding factors. This analysis included 1122 patients from the first and 568 patients from the second wave. Patients in the second wave were sicker, had more comorbidities, and had worse oxygenation parameters. They were ventilated with lower positive end-expiratory pressure and higher fraction inspired oxygen, had a lower oxygen saturation, received neuromuscular blockade more often, and were less often tracheostomized. Duration of ventilation was shorter, but mortality rates were similar. After matching, the fraction of inspired oxygen was lower in the second wave. In patients with acute hypoxemic respiratory failure due to COVID-19, aspects of respiratory care and outcomes rapidly changed over the successive waves.
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Affiliation(s)
- Liselotte Hol
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX37BN, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Street, Leinster, D08 NYH1 Dublin, Ireland
- Department of Clinical Medicine, Trinity College, D02 PN40 Dublin, Ireland
| | - David M P van Meenen
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Critical Care Medicine, Hospital Israelite Albert Einstein, Sao Paolo 05652-900, Brazil
- Department of Critical Care Medicine, Austin Hospital and University of Melbourne, Melbourne 3084, Australia
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, 1091 GC Amsterdam, The Netherlands
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233
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da Silva MDAP, Corradi-Perini C. The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review. Indian J Palliat Care 2023; 29:234-242. [PMID: 37700891 PMCID: PMC10493695 DOI: 10.25259/ijpc_292_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/27/2023] [Indexed: 09/14/2023] Open
Abstract
Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.
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Affiliation(s)
| | - Carla Corradi-Perini
- Bioethics Graduate Program, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Watanabe A, Malik A, Aikawa T, Briasoulis A, Kuno T. Extracorporeal membrane oxygenation for COVID-19-associated acute respiratory distress syndrome: A nationwide analysis. J Med Virol 2023; 95:e28961. [PMID: 37477642 DOI: 10.1002/jmv.28961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/13/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used for COVID-19-associated acute respiratory distress syndrome (ARDS). We aimed to elucidate the association between ECMO and mortality in patients with COVID-19-associated ARDS in the nationwide setting. United States National Inpatient Sample was used to identify mechanically ventilated adults for COVID-19 with ARDS. We divided them into three groups according to the use of ECMO (i.e., no-ECMO, venovenous [VV]-ECMO, and venoarterial [VA]-ECMO). The primary outcome was in-hospital mortality, while the secondary outcomes included the length of hospital stay (LOS) and the total costs during hospitalization. We performed a stepwise logistic regression, adjusting for baseline characteristics, comorbidities, and severity. We included 68 795 (mean age [SD]: 63.5 [0.1]), 3280 (mean age [SD]: 48.7 [0.5]), and 340 (mean age [SD]: 43.3 [2.1]) patients who received no-, VV-, and VA-ECMO, respectively. The logistic regression analysis did not show significant associations between the use of VV-/VA-ECMO and mortality (adjusted odds ratio with no-ECMO as reference [95% confidence interval]: 1.03 [0.86-1.24] and 1.18 [0.64-2.15], respectively). While LOS was longest with VV-ECMO, the total costs were highest with VA-ECMO. In conclusion, our study found no association between the use of ECMO and mortality of COVID-19-associated ARDS in the nationwide setting.
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Affiliation(s)
- Atsuyuki Watanabe
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Aaqib Malik
- Department of Medicine, Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Tadao Aikawa
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa City, Iowa, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
- Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
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235
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Pollack BE, Barbaro RP, Gorga SM, Carlton EF, Gaies M, Kohne JG. Hospital ECMO capability is associated with survival in pediatric cardiac arrest. Resuscitation 2023; 188:109853. [PMID: 37245647 PMCID: PMC10576981 DOI: 10.1016/j.resuscitation.2023.109853] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/01/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
AIM Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital's ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital. METHODS We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival. RESULTS We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support. CONCLUSION A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.
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Affiliation(s)
- Blythe E Pollack
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, United States.
| | - Ryan P Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, United States; Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Stephen M Gorga
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, United States
| | - Erin F Carlton
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, United States; Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Michael Gaies
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Joseph G Kohne
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, United States; Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, MI, United States
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Scheen AJ. Use of SGLT2 inhibitors after bariatric/metabolic surgery: Risk/benefit balance. Diabetes Metab 2023; 49:101453. [PMID: 37245675 DOI: 10.1016/j.diabet.2023.101453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/30/2023]
Abstract
Bariatric/metabolic surgery and sodium-glucose cotransporter 2 inhibitors (SGLT2is) are becoming increasingly popular for the management of overweight/obese patients with type 2 diabetes mellitus (T2DM). Consequently, the chance that a patient undergoing bariatric/metabolic surgery is also treated with an SGLT2i would be rather common in clinical practice. Both risks and benefits have been reported. On the one hand, several cases of euglycemic diabetic ketoacidosis have been reported within the few days/weeks after bariatric/metabolic surgery. The causes are diverse but a drastic reduction in caloric (carbohydrate) intake most probably plays a crucial role. Thus, SGLT2is should be stopped a few days (and even more if a pre-operative restricted diet is prescribed to reduce liver volume) before the intervention and reintroduced only when the caloric (carbohydrate) intake is sufficient. On the other hand, SGLT2is may exert a favorable effect to reduce the risk of postprandial hypoglycemia, a complication reported among patients who have been treated with bariatric/metabolic surgery. An increased hepatic glucose production and a reduced production of interleukin-1β have been proposed as possible underlying mechanisms for this protective effect. Finally, whether SGLT2is could prolong diabetes remission following surgery and improve the prognosis of patients with T2DM who benefit from bariatric/metabolic surgery remains to be investigated.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium.
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Ferrel MN, Raza SS, Tang P, Haft J, Ala AAE. Cannulation strategies for extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2023; 39:91-100. [PMID: 37525707 PMCID: PMC10387010 DOI: 10.1007/s12055-023-01537-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 08/02/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a type of extracorporeal life support (ECLS) in which the function of the heart and/or lungs is partially or completely replaced by a portable system that provides prolonged support to critically ill patients with respiratory or cardiac failure. There are two major variants of ECMO: veno-venous (VV) ECMO and veno-arterial (VA) ECMO. VV ECMO replaces the function of the lung in which it uses a cannula to remove venous blood and oxygenates it using the extracorporeal system, and returns the blood to the right atrium to be pumped to the body. VA ECMO is slightly different in that it replaces the function of the heart and lungs by returning oxygenated blood to the aorta. As a therapy for respiratory failure, ECMO minimizes hypoxia, diminishes lung stress and strain, and allows lung protective mechanical ventilation. As a support for acute and terminal heart failure, ECMO reduces preload, increases aortic flow, and allows for end-organ perfusion. Due to its physiological support and advantages, it is used for a variety of chronic and acute support purposes such as bridge therapy for heart/lung transplant, durable ventricular assist devices, and intermediate-term mechanical support postoperatively. Our review gives a broad overview of the two main types of ECMO strategies and their clinical indications, cannulation strategies, unique clinical utility, and their limitations.
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Affiliation(s)
| | - Syed Sikandar Raza
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48197 USA
| | - Paul Tang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48197 USA
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48197 USA
| | - Ashraf Abou El Ala
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48197 USA
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Teijeiro-Paradis R, Grenier J, Urner M, Douflé G, Steel A, Cypel M, Keshavjee S, Herridge M, Goligher E, Granton J, Ferguson N, Fan E, Del Sorbo L. Outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation: a prospective observational study. Can J Anaesth 2023; 70:1226-1233. [PMID: 37280459 PMCID: PMC10243882 DOI: 10.1007/s12630-023-02501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 06/08/2023] Open
Abstract
PURPOSE Descriptive information on referral patterns and short-term outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation (ECMO) is lacking. METHODS We conducted a prospective single-centre observational cohort study of ECMO referrals to Toronto General Hospital (receiving hospital) for severe respiratory failure (COVID-19 and non-COVID-19), between 1 December 2019 and 30 November 2020. Data related to the referral, the referral decision, and reasons for refusal were collected. Reasons for refusal were grouped into three mutually exclusive categories selected a priori: "too sick now," "too sick before," and "not sick enough." In declined referrals, referring physicians were surveyed to collect patient outcome on day 7 after the referral. The primary study endpoints were referral outcome (accepted/declined) and patient outcome (alive/deceased). RESULTS A total of 193 referrals were included; 73% were declined for transfer. Referral outcome was influenced by age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95 to 0.96; P < 0.01) and involvement of other members of the ECMO team in the discussion (OR, 4.42; 95% CI, 1.28 to 15.2; P < 0.01). Patient outcomes were missing in 46 (24%) referrals (inability to locate the referring physician or the referring physician being unable to recall the outcome). Using available data (95 declined and 52 accepted referrals; n = 147), survival to day 7 was 49% for declined referrals (35% for patients deemed "too sick now," 53% for "too sick before," 100% for "not sick enough," and 50% for reason for refusal not reported) and 98% for transferred patients. Sensitivity analysis setting missing outcomes to directional extreme values retained robustness of survival probabilities. CONCLUSION Nearly half of the patients declined for ECMO consideration were alive on day 7. More information on patient trajectory and long-term outcomes in declined referrals is needed to refine selection criteria.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jasmine Grenier
- Department of Critical Care, Scarborough Health Network, Scarborough, ON, Canada
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Steel
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Margaret Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada.
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Battaglini D, Iavarone IG, Robba C, Ball L, Silva PL, Rocco PRM. Mechanical ventilation in patients with acute respiratory distress syndrome: current status and future perspectives. Expert Rev Med Devices 2023; 20:905-917. [PMID: 37668146 DOI: 10.1080/17434440.2023.2255521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/14/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Although there has been extensive research on mechanical ventilation for acute respiratory distress syndrome (ARDS), treatment remains mainly supportive. Recent studies and new ventilatory modes have been proposed to manage patients with ARDS; however, the clinical impact of these strategies remains uncertain and not clearly supported by guidelines. The aim of this narrative review is to provide an overview and update on ventilatory management for patients with ARDS. AREAS COVERED This article reviews the literature regarding mechanical ventilation in ARDS. A comprehensive overview of the principal settings for the ventilator parameters involved is provided as well as a report on the differences between controlled and assisted ventilation. Additionally, new modes of assisted ventilation are presented and discussed. The evidence concerning rescue strategies, including recruitment maneuvers and extracorporeal membrane oxygenation support, is analyzed. PubMed, EBSCO, and the Cochrane Library were searched up until June 2023, for relevant literature. EXPERT OPINION Available evidence for mechanical ventilation in cases of ARDS suggests the use of a personalized mechanical ventilation strategy. Although promising, new modes of assisted mechanical ventilation are still under investigation and guidelines do not recommend rescue strategies as the standard of care. Further research on this topic is required.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Zhang T, Nikouline A, Riggs J, Nolan B, Pan A, Peddle M, Fan E, Del Sorbo L, Granton J. Outcomes of Patients Transported in the Prone Position to a Regional Extracorporeal Membrane Oxygenation Center: A Retrospective Cohort Study. Crit Care Explor 2023; 5:e0948. [PMID: 37492857 PMCID: PMC10365187 DOI: 10.1097/cce.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Prone positioning is associated with improved mortality in patients with moderate/severe acute respiratory distress syndrome (ARDS) and has been increasingly used throughout the COVID-19 pandemic. In patients with refractory hypoxemia, transfer to an extracorporeal membrane oxygenation (ECMO) center may improve outcome but may be challenging due to severely compromised gas exchange. Transport of these patients in prone position may be advantageous; however, there is a paucity of data on their outcomes. OBJECTIVES The primary objective of this retrospective cohort study was to describe the early outcomes of ARDS patients transported in prone position for evaluation at a regional ECMO center. A secondary objective was to examine the safety of their transport in the prone position. DESIGN Retrospective cohort study. SETTING This study used patient charts from Ornge and Toronto General Hospital in Ontario, Canada, between February 1, 2020, and November 31, 2021. PARTICIPANTS Patient with ARDS transported in the prone position for ECMO evaluation to Toronto General Hospital. MAIN OUTCOMES AND MEASURES Descriptive analysis of patients transported in the prone position and their outcomes. RESULTS One hundred fifteen patients were included. Seventy-two received ECMO (63%) and 51 died (44%) with ARDS and sepsis as the most common listed causes of death. Patients were transported primarily for COVID-related indications (93%). Few patients required additional analgesia (8%), vasopressors (4%), or experienced clinically relevant desaturation during transport (2%). CONCLUSIONS AND RELEVANCE This cohort of patients with severe ARDS transported in prone position had outcomes ranging from similar to better compared with existing literature. Prone transport was performed safely with few complications or escalation in treatments. Prone transport to an ECMO center should be regarded as safe and potentially beneficial for patients with ARDS and refractory hypoxemia.
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Affiliation(s)
- Timothy Zhang
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anton Nikouline
- Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jamie Riggs
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brodie Nolan
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Ornge, Mississauga, ON, Canada
| | - Andy Pan
- Ornge, Mississauga, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Critical Care Medicine, Montfort Hospital, Ottawa, ON, Canada
| | - Michael Peddle
- Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Ornge, Mississauga, ON, Canada
| | - Eddy Fan
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Tiruvoipati R, Akkanti B, Dinh K, Barrett N, May A, Kimmel J, Conrad SA. Extracorporeal Carbon Dioxide Removal With the Hemolung in Patients With Acute Respiratory Failure: A Multicenter Retrospective Cohort Study. Crit Care Med 2023; 51:892-902. [PMID: 36942957 PMCID: PMC10262985 DOI: 10.1097/ccm.0000000000005845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVES Extracorporeal carbon dioxide removal (ECCO 2 R) devices are effective in reducing hypercapnia and mechanical ventilation support but have not been shown to reduce mortality. This may be due to case selection, device performance, familiarity, or the management. The objective of this study is to investigate the effectiveness and safety of a single ECCO 2 R device (Hemolung) in patients with acute respiratory failure and identify variables associated with survival that could help case selection in clinical practice as well as future research. DESIGN Multicenter, multinational, retrospective review. SETTING Data from the Hemolung Registry between April 2013 and June 2021, where 57 ICUs contributed deidentified data. PATIENTS Patients with acute respiratory failure treated with the Hemolung. The characteristics of patients who survived to ICU discharge were compared with those who died. Multivariable logistical regression analysis was used to identify variables associated with ICU survival. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 159 patients included, 65 (41%) survived to ICU discharge. The survival was highest in status asthmaticus (86%), followed by acute respiratory distress syndrome (ARDS) (52%) and COVID-19 ARDS (31%). All patients had a significant reduction in Pa co2 and improvement in pH with reduction in mechanical ventilation support. Patients who died were older, had a lower Pa o2 :F io2 (P/F) and higher use of adjunctive therapies. There was no difference in the complications between patients who survived to those who died. Multivariable regression analysis showed non-COVID-19 ARDS, age less than 65 years, and P/F at initiation of ECCO 2 R to be independently associated with survival to ICU discharge (P/F 100-200 vs <100: odds ratio, 6.57; 95% CI, 2.03-21.33). CONCLUSIONS Significant improvement in hypercapnic acidosis along with reduction in ventilation supports was noted within 4 hours of initiating ECCO 2 R. Non-COVID-19 ARDS, age, and P/F at commencement of ECCO 2 R were independently associated with survival.
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Affiliation(s)
| | - Bindu Akkanti
- Department of Medicine, Division of Critical Care, Pulmonary and Sleep, University of Texas McGovern Medical School, Houston, TX
- Advanced Cardiopulmonary Therapeutics and Transplantation, University of Texas Health-Houston, Houston, TX
| | - Kha Dinh
- Department of Medicine, Division of Critical Care, Pulmonary and Sleep, University of Texas McGovern Medical School, Houston, TX
- Advanced Cardiopulmonary Therapeutics and Transplantation, University of Texas Health-Houston, Houston, TX
| | - Nicholas Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | | | | | - Steven A Conrad
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
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Ferrer Gómez C, Gabaldón T, Hernández Laforet J. Ultraprotective Ventilation via ECCO2R in Three Patients Presenting an Air Leak: Is ECCO2R Effective? J Pers Med 2023; 13:1081. [PMID: 37511692 PMCID: PMC10381516 DOI: 10.3390/jpm13071081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Extracorporeal CO2 removal (ECCO2R) is a therapeutic approach that allows protective ventilation in acute respiratory failure by preventing hypercapnia and subsequent acidosis. The main indications for ECCO2R in acute respiratory failure are COPD (chronic obstructive pulmonary disease) exacerbation, acute respiratory distress syndrome (ARDS) and other situations of asthmatics status. However, CO2 removal procedure is not extended to those ARDS patients presenting an air leak. Here, we report three cases of air leaks in patients with an ARDS that were successfully treated using a new ECCO2R device. Case 1 is a polytrauma patient that developed pneumothorax during the hospital stay, case 2 is a patient with a post-surgical bronchial fistula after an Ivor-Lewis esophagectomy, and case 3 is a COVID-19 patient who developed a spontaneous pneumothorax after being hospitalized for a prolonged time. ECCO2R allowed for protective ventilation mitigating VILI (ventilation-induced lung injury) and significantly improved hypercapnia and respiratory acidemia, allowing time for the native lung to heal. Although further investigation is needed, our observations seem to suggest that CO2 removal can be a safe and effective procedure in patients connected to mechanical ventilation with ARDS-associated air leaks.
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Affiliation(s)
- Carolina Ferrer Gómez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Tania Gabaldón
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Javier Hernández Laforet
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
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244
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Nyholm L, Zetterling M, Elf K. Sleep in neurointensive care patients, and patients after brain tumor surgery. PLoS One 2023; 18:e0286389. [PMID: 37352254 PMCID: PMC10289440 DOI: 10.1371/journal.pone.0286389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/09/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Severely brain injured patients treated in the neuro intensive care unit (NICU) are usually sedated. Sedation may affect not only the ability to sleep, but also the EEG rhythms used to identify sleep. AIM The aims were: To study if sleep patterns could be identified in the severely brain injured and sedated patients in the NICUTo study if sleep patterns could be identified in patients the night after brain tumor surgery in the neurointermediate care unit (NIMCU)To search for risk factors for not being able to sleep after brain tumor surgery. STUDY DESIGN Two populations were included; one with patients affected by severe brain injury and one with patients who had undergone planned brain tumor surgery. This was a quantitative observational study using EEG. Eligible neurointensive care patients for this study had to be suffering from a neurosurgical condition (for example subarachnoid haemorrhage, acute subdural hematoma, intracerebral haemorrhage and meningitis), have affected consciousness and age over 18 years. Thirty-seven patients were included from NICU. Ninety-eight patients, with a suspected glioma (WHO grade II-IV) planned for surgery were also included. RESULTS Neuro intensive care patients, sedated and treated in ventilator, showed no EEG sleep patterns at all. After brain tumor surgery, sleep occurred in 74% of the patients, despite frequent wake-up tests. The patients with sleep patterns were on average 8 years younger, p = 0.03. CONCLUSIONS Patients with severe brain injury are at risk of having no sleep when treated at the NICU, whereas after brain tumor surgery, sleep occurs in three-fourths of the patients. Further studies and new methods are warranted to identify sleep and investigate how the loss of sleep affects these patients and how sleep disturbances can be managed.
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Affiliation(s)
- Lena Nyholm
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Maria Zetterling
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Kristin Elf
- Department of Medical Sciences, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
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Cao W, He N, Luo Y, Zhang Z. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxic respiratory failure: a systematic review based on eight high-quality randomized controlled trials. BMC Infect Dis 2023; 23:415. [PMID: 37337193 PMCID: PMC10278266 DOI: 10.1186/s12879-023-08393-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Awake prone positioning has been widely used in non-intubated patients with acute hypoxic respiratory failure (AHRF) due to COVID-19, but the evidence is mostly from observational studies and low-quality randomized controlled trials (RCTs), with conflicting results from published studies. A systematic review of published high-quality RCTs to resolve the controversy over the efficacy and safety of awake prone positioning in non-intubated patients with AHRF due to COVID-19. METHODS Candidate studies were identified through searches of PubMed, Web of Science, Cochrane, Embase, Scopus databases from December 1, 2019 to November 1, 2022. Literature screening, data extraction and risk of bias assessment were independently conducted by two researchers. RESULTS Eight RCTs involving 2657 patients were included. Meta-analysis of fixed effects models showed that awake prone positioning did not increase mortality(OR = 0.88, 95%CI [0.72, 1.08]), length of stay in ICU (WMD = 1.14, 95%CI [-0.45, 2.72]), total length of stay (WMD = 0.11, 95%CI [-1.02, 1.23]), or incidence of adverse events (OR = 1.02, 95%CI [0.79, 1.31]) compared with usual care, but significantly reduced the intubation rate (OR = 0.72, 95%CI [0.60, 0.86]). Similar results were found in a subgroup analysis of patients who received only high flow nasal cannula (Mortality: OR = 0.86, 95%CI [0.70, 1.05]; Intubation rate: OR = 0.69, 95%CI [0.58, 0.83]). All eight RCTs had high quality of evidence, which ensured the reliability of the meta-analysis results. CONCLUSIONS Awake prone positioning is safe and feasible in non-intubated patients with AHRF caused by COVID-19, and can significantly reduce the intubation rate. More studies are needed to explore standardized implementation strategies for the awake prone positioning. TRIAL REGISTRATION CRD42023394113.
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Affiliation(s)
- Wen Cao
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China.
| | - Nannan He
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China
| | - Yannian Luo
- Department of Critical Medicine, the Second Hospital of Lanzhou University, Lanzhou, 730030, China
| | - Zhiming Zhang
- Department of Oncology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, 730030, China.
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Choi S, Hong KJ, Lee SGW, Kim TH, Shin SD, Song KJ, Ro YS, Jeong J, Park JH, Lee GM. Association between Case Volumes of Extracorporeal Life Support and Clinical Outcome in Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:139-146. [PMID: 37216581 DOI: 10.1080/10903127.2023.2216786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 05/24/2023]
Abstract
AIM Extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) is increasing. There is little evidence identifying the association between hospital ECLS case volumes and outcomes in different populations receiving ECLS or conventional cardiopulmonary resuscitation (CPR). The goal of this investigation was to identify the association between ECLS case volumes and clinical outcomes of OHCA patients. METHODS This cross-sectional observational study used the National OHCA Registry for adult OHCA cases in Seoul, Korea between January 2015 and December 2019. If the ECLS volume during the study period was >20, the institution was defined as a high-volume ECLS center. Others were defined as low-volume ECLS centers. Outcomes were good neurologic recovery (cerebral performance category 1 or 2) and survival to discharge. We performed multivariate logistic regression and interaction analyses to assess the association between case volume and clinical outcome. RESULTS Of the 17,248 OHCA cases, 3,731 were transported to high-volume centers. Among the patients who underwent ECLS, those at high-volume centers had a higher neurologic recovery rate than those at low-volume centers (17.0% vs. 12.0%), and the adjusted OR for good neurologic recovery was 2.22 (95% confidence interval (CI): 1.15-4.28) in high-volume centers compared to low-volume centers. For patients who received conventional CPR, high-volume centers also showed higher survival-to-discharge rates (adjusted OR of 1.16, 95%CI: 1.01-1.34). CONCLUSIONS High-volume ECLS centers showed better neurological recovery in patients who underwent ECLS. High-volume centers also had better survival-to-discharge rates than low-volume centers for patients not receiving ECLS.
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Affiliation(s)
- Seulki Choi
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University, Seoul, South Korea
| | - Stephen Gyung Won Lee
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Tae Han Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University, Seoul, South Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University, Seoul, South Korea
| | - Joo Jeong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University, Seoul, South Korea
| | - Gyeong Min Lee
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
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Mbuagbaw L, Chen LH, Aluko E, Stevens-Uninsky M, Eze-Onuorah ACJ, Garcia MC, Stech L, Atkin-Jones T, Rehman N, Raifu A. Empirical progression criteria thresholds for feasibility outcomes in HIV clinical trials: a methodological study. Pilot Feasibility Stud 2023; 9:96. [PMID: 37316946 DOI: 10.1186/s40814-023-01342-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Pilot and feasibility trials use predetermined thresholds for feasibility outcomes to decide if a larger trial is feasible. These thresholds may be derived from the literature, observational data, or clinical experience. The aim of this study was to determine empirical estimates for feasibility outcomes to inform future HIV pilot randomized trials. METHODS We conducted a methodological study of HIV clinical trials indexed in the past 5 years (2017-2021) in the PubMed database. We included trials of people living with HIV individually randomized to any type of intervention and excluded pilot trials and cluster randomized trials. Screening and data extraction were conducted in duplicate. We computed estimates for recruitment, randomization, non-compliance, lost to follow-up, discontinuation, and the proportion analyzed using a random effects meta-analysis of proportions and reported these estimates according to the following subgroups: use of medication, intervention type, trial design, income level, WHO region, participant type, comorbidities, and source of funding. We report estimates with 95% confidence intervals. RESULTS We identified 2122 studies in our search, of which 701 full texts were deemed relevant, but only 394 met our inclusion criteria. We found the following estimates: recruitment (64.1%; 95% CI 57.7 to 70.3; 156 trials); randomization (97.1%; 95% CI 95.8 to 98.3; 187 trials); non-compliance (3.8%; 95% CI 2.8 to 4.9; 216 trials); lost to follow-up (5.8%; 95% CI 4.9 to 6.8; 251 trials); discontinuation (6.5%; 95% CI 5.5 to 7.5; 215 trials); analyzed (94.2%; 95% CI 92.9 to 95.3; 367 trials). There were differences in estimates across most subgroups. CONCLUSION These estimates may be used to inform the design of HIV pilot randomized trials with careful consideration of variations due to some of the subgroups investigated.
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Affiliation(s)
- Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada.
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa.
| | - Lucy Huizhu Chen
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Eunice Aluko
- Faculty of Arts and Science, University of Toronto, Toronto, ON, Canada
| | - Maya Stevens-Uninsky
- Department of Global Health, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | | | - Larysa Stech
- Public Health, Faculty of Applied Sciences, Brock University, St. Catharines, ON, Canada
| | - Tariq Atkin-Jones
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nadia Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Amidu Raifu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
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Hayat Syed MK, Bruck O, Kumar A, Surani S. Acute exacerbation of interstitial lung disease in the intensive care unit: Principles of diagnostic evaluation and management. World J Crit Care Med 2023; 12:153-164. [PMID: 37397591 PMCID: PMC10308341 DOI: 10.5492/wjccm.v12.i3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/18/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023] Open
Abstract
Interstitial lung disease (ILD) is typically managed on an outpatient basis. Critical care physicians manage patients with ILD in the setting of an acute exacerbation (ILD flare) causing severe hypoxia. The principles of management of acute exacerbation of ILD are different from those used to manage patients with acute respiratory distress syndrome from sepsis, etc. Selected patients may be candidates for aggressive measures like extracorporeal membrane oxygenation and lung transplantation, while almost all patients will benefit from early palliative care. This review focused on the types of ILD, diagnosis, and management pathways for this challenging condition.
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Affiliation(s)
- Muhammad K Hayat Syed
- Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Or Bruck
- Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Anupam Kumar
- Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A&M University, College Station, TX 77843, United States
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249
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Gao M, Wen W, Gu C, Zhang X, Yu Y, Li H. Coronary plaque burden predicts perioperative cardiovascular events after coronary endarterectomy. Front Cardiovasc Med 2023; 10:1175287. [PMID: 37363096 PMCID: PMC10289079 DOI: 10.3389/fcvm.2023.1175287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Background and aims The risk factors of perioperative and long-term cardiovascular events in patients undergoing coronary artery bypass grafting (CABG) with adjunctive coronary endarterectomy (CE) are not well determined. This study evaluated the clinical value of coronary plaque burden, coronary anatomic stenosis, and serum biomarkers for predicting perioperative cardiovascular events after off-pump CABG + CE. Methods This retrospective cohort single-center study enrolled 125 patients undergoing off-pump CABG + CE between February 2018 and September 2021 in China. Coronary plaque burden was reflected by the length of plaque removed by CE. Plaque length-max, which represents the plaque length in patients undergoing single-vessel CE and the maximum plaque length in patients undergoing multivessel CE, was calculated. The primary endpoint was perioperative myocardial infraction (PMI). Results Plaque length-max was significantly higher in patients with PMI than in those without PMI (2.4 ± 1.5 vs. 1.6 ± 0.9, p = .001). A threshold plaque length-max of 1.15 cm was an independent predictor of PMI (area under the curve: 0.67; sensitivity 87.9%; specificity 59.8%; p = .005). Patients with plaque length-max ≥1.15 had a > 5-fold increase in PMI after adjusting for confounding factors (odds ratio = 5.89; p = .002). Furthermore, interleukin-6 (Beta = .32: p = .028), CD68 (Beta = .34; p = .045), and osteopontin (Beta = .43; p = .008) were significantly correlated with plaque length-max. Conclusions Plaque length-max was superior to clinical cardiovascular risk factors in predicting PMI occurrence after off-pump CABG + CE, which might be associated with systemic and plaque inflammation state.
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Affiliation(s)
- Mingxin Gao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wanwan Wen
- Department of Nuclear Medicine, Molecular Imaging Lab, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chengxiong Gu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - XiaoLi Zhang
- Department of Nuclear Medicine, Molecular Imaging Lab, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Yu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haiyang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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