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Sandrio S, Beck G, Krebs J, Otto M. [Peripheral extracorporeal membrane oxygenation in perioperative medicine : Principles, indications and challenges]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02135-5. [PMID: 39145870 DOI: 10.1007/s00104-024-02135-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/16/2024]
Abstract
In recent years the number of patients treated in intensive care units by extracorporeal membrane oxygenation (ECMO) due to severe respiratory failure or cardiogenic shock has steadily increased [1]. Consequently, the number of invasive procedures and operations in these patients has also increased. A fundamental understanding of these systems and the clinical indications is therefore helpful for the practicing (non-cardiac) surgeon. This review article focuses on peripheral ECMO procedures: venovenous (V-V) ECMO for patients with respiratory failure and venoarterial (V-A) ECMO for circulatory support in cardiogenic shock.
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Affiliation(s)
- Stany Sandrio
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Grietje Beck
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Joerg Krebs
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Matthias Otto
- Klinik für Anästhesiologie, Operative Intensiv- und Schmerzmedizin, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Müller MC, Wilke SK, Dobbermann A, Kirsten S, Ruß M, Weber-Carstens S, Wollersheim T. Dissolved Oxygen Relevantly Contributes to Systemic Oxygenation During Venovenous Extracorporeal Membrane Oxygenation Support. ASAIO J 2024; 70:667-674. [PMID: 38446867 PMCID: PMC11280439 DOI: 10.1097/mat.0000000000002171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
When determining extracorporeal oxygen transfer (V ML O 2 ) during venovenous extracorporeal membrane oxygenation (VV ECMO) dissolved oxygen is often considered to play a subordinate role due to its poor solubility in blood plasma. This study was designed to assess the impact of dissolved oxygen on systemic oxygenation in patients with acute respiratory distress syndrome (ARDS) on VV ECMO support by differentiating between dissolved and hemoglobin-bound extracorporeal oxygen transfer. We calculated both extracorporeal oxygen transfer based on blood gas analysis using the measuring energy expenditure in extracorporeal lung support patients (MEEP) protocol and measured oxygen uptake by the native lung with indirect calorimetry. Over 20% of V ML O 2 and over 10% of overall oxygen uptake (VO 2 total ) were realized as dissolved oxygen. The transfer of dissolved oxygen mainly depended on ECMO blood flow (BF ML ). In patients with severely impaired lung function dissolved oxygen accounted for up to 28% of VO 2 total . A clinically relevant amount of oxygen is transferred as physically dissolved fraction, which therefore needs to be considered when determining membrane lung function, manage ECMO settings or guiding the weaning procedure.
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Affiliation(s)
- Michael C. Müller
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah K. Wilke
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Andrej Dobbermann
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Kirsten
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ruß
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Steffen Weber-Carstens
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Wollersheim
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité – Universitätsmedizin Berlin, Berlin, Germany
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Linden K, Schmandt M, Muders T, Theuerkauf N, Schewe JC, Herberg U, Putensen C, Ehrentraut SF, Kreyer S. Estimation of Cardiac Output Under Veno-Venous Extracorporeal Membrane Oxygenation: Comparing Thermodilution Methods to 3D Echocardiography. ASAIO J 2024:00002480-990000000-00533. [PMID: 39074443 DOI: 10.1097/mat.0000000000002283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
Thermodilution methods to determine cardiac output (CO) may be affected by veno-venous extracorporeal membrane oxygenation (ECMO). We compared CO estimations by pulmonary arterial thermodilution using a pulmonary arterial catheter (COPAC), transpulmonary thermodilution (COTPTD), and three-dimensional echocardiography (3DEcho) (CO3DEcho) in 18 patients under veno-venous ECMO. Comparisons between CO3DEcho and COPAC, and COTPTD were performed using correlation statistics and Bland-Altman analysis. Blood flow on ECMO support ranged from 4.3 to 5.8 L/min (median 4.9 L/min). Cardiac output measured with three-dimensional echocardiography was 5.2 L/min (3.8/5.9), COPAC was 7.3 L/min (5.9/7.9), and COTPTD was 7.3 L/min (6/8.2) (median [25%/75% percentile]). Bland-Altman analysis of CO3DEcho and COPAC revealed a mean bias of -2.06 L/min, with limits of agreement from -4.16 to 0.04 L/min. Bland-Altman analysis of CO3DEcho and COTPTD revealed a mean bias of -2.22 L/min, with limits of agreement from -4.18 to -0.25 L/min. We found a negative mean bias and negative limits of agreement between CO3DEcho and COPAC/COTPTD. We concluded an influence on the estimation of CO by thermodilution under ECMO most likely due to loss of indicator resulting in an overestimation of CO. Clinicians should consider this when monitoring thermodilution-based CO under ECMO.
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Affiliation(s)
- Katharina Linden
- From the Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
- Department of Pediatric Cardiology, University Hospital Aachen, Aachen, Germany
| | - Mathias Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Muders
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Nils Theuerkauf
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre Rostock, Rostock, Germany
| | - Ulrike Herberg
- From the Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
- Department of Pediatric Cardiology, University Hospital Aachen, Aachen, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Stefan Felix Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Masi P, Gouriet L, Radu C, Folliguet T, Fiore A, Gallet R, Bagate F, Mekontso Dessap A, De Prost N. Immediate Clinical Complications Occurring During Membrane Change in Patients on Veno-Venous Extracorporeal Membrane Oxygenation. ASAIO J 2024:00002480-990000000-00530. [PMID: 39052935 DOI: 10.1097/mat.0000000000002270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
The clinical tolerance of extracorporeal membrane oxygenation (ECMO) membrane changes in acute respiratory distress syndrome (ARDS) patients under veno-venous ECMO (VV-ECMO) has not been reported. The aim of this study was to describe the tolerance of membrane change. Patients requiring VV-ECMO were retrospectively included between March 2020 and May 2022. In case of membrane dysfunction or an increase in hemolysis markers or an alteration in gas exchange, a membrane change was performed. The primary outcome was a composite measure defined as the occurrence of at least one of the following events within 1 hour of membrane change: severe hypoxemia, hemodynamic collapse, bradycardia, arrhythmia, cardiac arrest, and death. During the study period, 70 patients required a VV-ECMO, 29 (41%) of whom died. Thirty-two patients required a membrane change for a total of 56 changes. The primary outcome occurred for 33 (59%) changes. Arterial desaturation <80% occurred for all complicated membrane changes and cardiac arrest concerned nine changes (16%). Low tidal volume (VT), respiratory system compliance (Crs), PaO2, and high ECMO blood flow (QECMO) were associated with poor tolerance of membrane change. Threshold values of 130 ml for VT, 9.3 cm H2O for Crs, 72 mm Hg for PaO2, and 3.65 L/minute for QECMO best determined the risk of poor tolerance of membrane change.
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Affiliation(s)
- Paul Masi
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Loic Gouriet
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Costin Radu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Thierry Folliguet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Antonio Fiore
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de chirurgie cardiaque, Departement Medico-Universitaire (DMU) CARE, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France; and
| | - Romain Gallet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de cardiologie, Créteil, France
| | - François Bagate
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Armand Mekontso Dessap
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
| | - Nicolas De Prost
- From the Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, Créteil, France
- Univ Paris Est Créteil, Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Créteil, France
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dos Santos YDAP, Cardozo LCM, Mendes PV, Besen BAMP, Park M. Factors associated with carbon dioxide transfer in an experimental model of severe acute kidney injury and hypoventilation during high bicarbonate continuous renal replacement therapy and oxygenation membrane support. CRITICAL CARE SCIENCE 2024; 36:e20240005en. [PMID: 38985048 PMCID: PMC11208041 DOI: 10.62675/2965-2774.20240005-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/26/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE To investigate the factors influencing carbon dioxide transfer in a system that integrates an oxygenation membrane in series with high-bicarbonate continuous veno-venous hemodialysis in hypercapnic animals. METHODS In an experimental setting, we induced severe acute kidney injury and hypercapnia in five female Landrace pigs. Subsequently, we initiated high (40mEq/L) bicarbonate continuous veno-venous hemodialysis with an oxygenation membrane in series to maintain a pH above 7.25. At intervals of 1 hour, 6 hours, and 12 hours following the initiation of continuous veno-venous hemodialysis, we performed standardized sweep gas flow titration to quantify carbon dioxide transfer. We evaluated factors associated with carbon dioxide transfer through the membrane lung with a mixed linear model. RESULTS A total of 20 sweep gas flow titration procedures were conducted, yielding 84 measurements of carbon dioxide transfer. Multivariate analysis revealed associations among the following (coefficients ± standard errors): core temperature (+7.8 ± 1.6 °C, p < 0.001), premembrane partial pressure of carbon dioxide (+0.2 ± 0.1/mmHg, p < 0.001), hemoglobin level (+3.5 ± 0.6/g/dL, p < 0.001), sweep gas flow (+6.2 ± 0.2/L/minute, p < 0.001), and arterial oxygen saturation (-0.5 ± 0.2%, p = 0.019). Among these variables, and within the physiological ranges evaluated, sweep gas flow was the primary modifiable factor influencing the efficacy of low-blood-flow carbon dioxide removal. CONCLUSION Sweep gas flow is the main carbon dioxide removal-related variable during continuous veno-venous hemodialysis with a high bicarbonate level coupled with an oxygenator. Other carbon dioxide transfer modulating variables included the hemoglobin level, arterial oxygen saturation, partial pressure of carbon dioxide and core temperature. These results should be interpreted as exploratory to inform other well-designed experimental or clinical studies.
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Affiliation(s)
- Yuri de Albuquerque Pessoa dos Santos
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Luis Carlos Maia Cardozo
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Pedro Vitale Mendes
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Bruno Adler Maccagnan Pinheiro Besen
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Marcelo Park
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
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Grotberg JC, Reynolds D, Kraft BD. Extracorporeal Membrane Oxygenation for Respiratory Failure: A Narrative Review. J Clin Med 2024; 13:3795. [PMID: 38999360 PMCID: PMC11242398 DOI: 10.3390/jcm13133795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/20/2024] [Accepted: 06/23/2024] [Indexed: 07/14/2024] Open
Abstract
Extracorporeal membrane oxygenation support for respiratory failure in the intensive care unit continues to have an expanded role in select patients. While acute respiratory distress syndrome remains the most common indication, extracorporeal membrane oxygenation may be used in other causes of refractory hypoxemia and/or hypercapnia. The most common configuration is veno-venous extracorporeal membrane oxygenation; however, in specific cases of refractory hypoxemia or right ventricular failure, some patients may benefit from veno-pulmonary extracorporeal membrane oxygenation or veno-venoarterial extracorporeal membrane oxygenation. Patient selection and extracorporeal circuit management are essential to successful outcomes. This narrative review explores the physiology of extracorporeal membrane oxygenation, indications and contraindications, ventilator management, extracorporeal circuit management, troubleshooting hypoxemia, complications, and extracorporeal membrane oxygenation weaning in patients with respiratory failure. As the footprint of extracorporeal membrane oxygenation continues to expand, it is essential that clinicians understand the underlying physiology and management of these complex patients.
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Affiliation(s)
- John C. Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63131, USA; (D.R.); (B.D.K.)
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Rixecker TM, Ast V, Rodriguez E, Mazuru V, Wagenpfeil G, Mang S, Muellenbach RM, Nobile L, Ajouri J, Bals R, Seiler F, Taccone FS, Lepper PM. Carbon Dioxide Targets in Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00509. [PMID: 38905594 DOI: 10.1097/mat.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
Target values for arterial carbon dioxide tension (PaCO2) in extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) are unknown. We hypothesized that lower PaCO2 values on ECMO would be associated with lighter sedation. We used data from two independent patient cohorts with ARDS spending 1,177 days (discovery cohort, 69 patients) and 516 days (validation cohort, 70 patients) on ECMO and evaluated the associations between daily PaCO2, pH, and bicarbonate (HCO3) with sedation. Median PaCO2 was 41 (interquartile range [IQR] = 37-46) mm Hg and 41 (IQR = 37-45) mm Hg in the discovery and the validation cohort, respectively. Lower PaCO2 and higher pH but not bicarbonate (HCO3) served as significant predictors for reaching a Richmond Agitation Sedation Scale (RASS) target range of -2 to +1 (lightly sedated to restless). After multivariable adjustment for mortality, tracheostomy, prone positioning, vasoactive inotropic score, Simplified Acute Physiology Score (SAPS) II or Sequential Organ Failure Assessment (SOFA) Score and day on ECMO, only PaCO2 remained significantly associated with the RASS target range (adjusted odds ratio 1.1 [95% confidence interval (CI) = 1.01-1.21], p = 0.032 and 1.29 [95% CI = 1.1-1.51], p = 0.001 per mm Hg decrease in PaCO2 for the discovery and the validation cohort, respectively). A PaCO2 ≤40 mm Hg, as determined by the concordance probability method, was associated with a significantly increased probability of a sedation level within the RASS target range in both patient cohorts (adjusted odds ratio = 2.92 [95% CI = 1.17-7.24], p = 0.021 and 6.82 [95% CI = 1.50-31.0], p = 0.013 for the discovery and the validation cohort, respectively).
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Affiliation(s)
- Torben M Rixecker
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Vanessa Ast
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Elianna Rodriguez
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vitalie Mazuru
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Gudrun Wagenpfeil
- Department of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Sebastian Mang
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Ralf M Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jonas Ajouri
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Robert Bals
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Frederik Seiler
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philipp M Lepper
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
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Brown A, Udy A, Burrell A, Joyce CJ. Beta-blockade for the treatment of refractory hypoxaemia during venovenous extracorporeal membrane oxygenation: An in-silico study. Perfusion 2024:2676591241262261. [PMID: 38881099 DOI: 10.1177/02676591241262261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
INTRODUCTION Venovenous extracorporeal membrane oxygenation (VV ECMO) is used for refractory hypoxemia, although despite this, in high cardiac output states, hypoxaemia may persist. The administration of beta-blockers has been suggested as an approach in this scenario, however the physiological consequences of this intervention are not clear. METHODS We performed an in-silico study using a previously described mathematical model to evaluate the effect of beta-blockade on mixed venous and arterial saturations (S v ¯ O 2 , SaO2), in three different clinical scenarios and considered the potential effects of beta-blockers on, cardiac output, oxygen consumption and recirculation. Additionally we assessed the interaction of beta-blockade with haemoglobin concentration. RESULTS In scenario 1: simulating a patient with high cardiac output and partial lung shunt S v ¯ O 2 decreased from increased 53.5% to 44.7% despite SaO2 rising from 74.2% to 79.2%. In scenario 2 simulating a patient with high cardiac output and complete lung shunt S v ¯ O 2 remained unchanged at 52.2% and SaO2 rose from 71.9% to 85%. In scenario 3 a patient with normal cardiac output and high recirculation S v ¯ O 2 fell from 50.8% to 25.5% and also fell from 82.4% to to 78.3%. Across the remaining modelling examples the effect on S v ¯ O 2 varied but oxygen delivery was consistently reduced across all scenarios. CONCLUSION The administration of beta-blockers for refractory hypoxemia during VV ECMO are unpredictable and may reduce oxygen delivery, although this will vary with patient and circuit features. This study does not support the use of beta-blockers for this indication.
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Affiliation(s)
- Alastair Brown
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Andrew Udy
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Aidan Burrell
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Christopher J Joyce
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Academy of Critical Care, University of Queensland, Brisbane, QLD, Australia
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Qian Z, He H, Wang Y, Geng S, Li Y, Yuan X, Zhang R, Yang Y, Qiu H, Liu S, Liu L. Evaluation of CO 2 removal rate of ECCO 2R for a renal replacement therapy platform in an experimental setting. Artif Organs 2024; 48:586-594. [PMID: 38304926 DOI: 10.1111/aor.14718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/04/2024] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND A critical parameter of extracorporeal CO2 removal (ECCO2R) applications is the CO2 removal rate (VCO2). Low-flow venovenous extracorporeal support with large-size membrane lung remains undefined. This study aimed to evaluate the VCO2 of a low-flow ECCO2R with large-size membrane lung using a renal replacement therapy platform in an experimental animal model. METHODS Twelve healthy pigs were placed under mechanical ventilation and connected to an ECCO2R-CRRT system (surface area = 1.8 m2; OMNIset®, BBraun, Germany). Respiratory settings were reduced to induce two degrees of hypercapnia. VCO2 was recorded under different combinations of PaCO2 (50-69 or 70-89 mm Hg), extracorporeal blood flow (ECBF; 200 or 350 mL/min), and gas flow (4, 6, or 10 L/min). RESULTS VCO2 increased with ECBF at all three gas flow rates. In severe hypercapnia, the increase in sweep gas flow from 4 to 10 L/min increased VCO2 from 86.38 ± 7.08 to 96.50 ± 8.71 mL/min at an ECBF of 350 mL/min, whereas at ECBF of 200 mL/min, any increase was less effective. But in mild hypercapnia, the increase in sweep gas flow result in significantly increased VCO2 at two ECBF. VCO2 increased with PaCO2 from 50-69 to 70-89 mm Hg at an ECBF of 350 mL/min, but not at ECBF of 200 mL/min. Post-membrane lung PCO2 levels were similar for different levels of premembrane lung PCO2 (p = 0.08), highlighting the gas exchange diffusion efficacy of the membrane lung in gas exchange diffusion. In severe hypercapnia, the reduction of PaCO2 elevated from 11.5% to 19.6% with ECBF increase only at a high gas flow of 10 L/min (p < 0.05) and increase of gas flow significantly reduced PaCO2 only at a high ECBF of 350 mL/min (p < 0.05). CONCLUSIONS Low-flow venovenous extracorporeal ECCO2R-CRRT with large-size membrane lung is more efficient with the increase of ECBF, sweep gas flow rate, and the degree of hypercapnia. The influence of sweep gas flow on VCO2 depends on the ECBF and degree of hypercapnia. Higher ECBF and gas flow should be chosen to reverse severe hypercapnia.
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Affiliation(s)
- Zhicheng Qian
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Department of Critical Care Medicine, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Hao He
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yuxuan Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Shike Geng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yang Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Songqiao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing, Jiangsu, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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10
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Nakamura T, Kuriyama N, Hara Y, Komura H, Hoshino N, Miyamoto S, Sawada K, Kawaji T, Komatsu S, Nishida O. Arterial oxygen pressure during veno-venous extracorporeal membrane oxygenation may be increased by advancing the tip of the drainage cannula into the superior vena cava: a case report. J Artif Organs 2024:10.1007/s10047-024-01448-w. [PMID: 38771405 DOI: 10.1007/s10047-024-01448-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/30/2024] [Indexed: 05/22/2024]
Abstract
A simple and robust method for veno-venous extracorporeal membrane oxygenation (V-V ECMO) involves a drainage cannula into the inferior vena cava via the femoral vein (FV) and a reinfusion cannula into the right atrium (RA) via the internal jugular vein (IJV) (F-J configuration). However, with this method, the arterial oxygen (PaO2) is said to remain below 100 mmHg.Since recently, in our ICU, to prevent drainage failure, we apply a modification from the commonly practiced F-J configuration by advancing the tip of the drainage cannula inserted via the FV into the superior vena cava (SVC) and crossing the reinfusion cannula inserted via the IJV in the RA (F(SVC)-J(RA) configuration). We experienced that this modification can be associated with unexpectedly high PaO2 values, which here we investigated in detail.Veno-arteriovenous ECMO was induced in a 65-year-old male patient who suffered from repeated cardiac arrest due to acute respiratory distress syndrome. His chest X-ray images showed white-out after lung rest setting, consistent with near-absence of self-lung ventilation. Cardiac function recovered and the system was converted to F(SVC)-J(RA) configuration, after which both PaO2 and partial pressure of pulmonary arterial oxygen values remained high above 200 mmHg. Transesophageal echocardiography could not detect right-to-left shunt, and more efficient drainage of the native venous return flow compared to common F-J configuration may explain the increased PaO2.Although the F(SVC)-J(RA) configuration is a small modification of the F-J configuration, it seems to provide a revolutionary improvement in the ECMO field by combining robustness/simplicity with high PaO2 values.
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Affiliation(s)
- Tomoyuki Nakamura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Naohide Kuriyama
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Hidefumi Komura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Naoki Hoshino
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Soshi Miyamoto
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Ken Sawada
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Takahiro Kawaji
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Satoshi Komatsu
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
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11
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Dave SB, Leiendecker E, Creel-Bulos C, Miller CF, Boorman DW, Javidfar J, Attia T, Daneshmand M, Jabaley CS, Caridi-Schieble M. Outcomes following additional drainage during veno-venous extracorporeal membrane oxygenation: A single-center retrospective study. Perfusion 2024:2676591241249609. [PMID: 38756070 DOI: 10.1177/02676591241249609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Refractory hypoxemia during veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) may require an additional cannula (VV-V ECMO) to improve oxygenation. This intervention includes risk of recirculation and other various adverse events (AEs) such as injury to the lung, cannula malpositioning, bleeding, circuit or cannula thrombosis requiring intervention (i.e., clot), or cerebral injury. During the study period, 23 of 142 V-V ECMO patients were converted to VV-V utilizing two separate cannulas for bi-caval drainage with an additional upper extremity cannula placed for return. Of those, 21 had COVID-19. In the first 24 h after conversion, ECMO flow rates were higher (5.96 vs 5.24 L/min, p = .002) with no significant change in pump speed (3764 vs 3630 revolutions per minute [RPMs], p = .42). Arterial oxygenation (PaO2) increased (87 vs 64 mmHg, p < .0001) with comparable pre-oxygenator venous saturation (61 vs 53.3, p = .12). By day 5, flows were similar to pre-conversion values at lower pump speed but with improved PaO2. Unadjusted survival was similar in those converted to VV-V ECMO compared to V-V ECMO alone (70% [16/23] vs 66.4% [79/119], p = .77). In a mixed effect regression model, any incidence of AEs, demonstrated a negative impact on PaO2 in the first 48 h but not at day 5. VV-V ECMO improved oxygenation with increasing flows without a significant difference in AEs or pump speed. AEs transiently impacted oxygenation. VV-V ECMO is effective and feasible strategy for refractory hypoxemia on VV-ECMO allowing for higher flow rate and unchanged pump speed.
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Affiliation(s)
- Sagar B Dave
- Department of Emergency Medicine, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Eric Leiendecker
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Christina Creel-Bulos
- Department of Emergency Medicine, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Casey Frost Miller
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - David W Boorman
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey Javidfar
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Tamer Attia
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mani Daneshmand
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Craig S Jabaley
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Mark Caridi-Schieble
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
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12
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Berger D, Stanger EJ, Jenni H, Fried PD, Bachmann KF. Modified Thermodilution for Simultaneous Cardiac Output and Recirculation Assessment in Veno-venous Extracorporeal Membrane Oxygenation: A Prospective Diagnostic Accuracy Study. Anesthesiology 2024; 140:1002-1015. [PMID: 38157435 DOI: 10.1097/aln.0000000000004895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Thermodilution is unreliable in veno-venous extracorporeal membrane oxygenation (VV-ECMO). Systemic oxygenation depends on recirculation fractions and ratios of extracorporeal membrane oxygenation (ECMO) flow to cardiac output. In a prospective in vitro simulation, this study assessed the diagnostic accuracy of a modified thermodilution technique for recirculation and cardiac output. The hypothesis was that this method provided clinically acceptable precision and accuracy for cardiac output and recirculation. METHODS Two ECMO circuits ran in parallel: one representing a VV-ECMO and the second representing native heart, lung, and circulation. Both circuits shared the right atrium. Extra limbs for recirculation and pulmonary shunt were added. This study simulated ECMO flows from 1 to 2.5 l/min and cardiac outputs from 2.5 to 3.5 l/min with recirculation fractions (0 to 80%) and pulmonary shunts. Thermistors in both ECMO limbs and the pulmonary artery measured the temperature changes induced by cold bolus injections into the arterial ECMO limb. Recirculation fractions were calculated from the ratio of the areas under the temperature curve (AUCs) in the ECMO limbs and from partitioning of the bolus volume (flow based). With known partitioning of bolus volumes between ECMO and pulmonary artery, cardiac output was calculated. High-precision ultrasonic flow probes served as reference for Bland-Altman plots and linear mixed-effect models. RESULTS Accuracy and precision for both the recirculation fraction based on AUC (bias, -5.4%; limits of agreement, -18.6 to 7.9%) and flow based (bias, -5.9%; limits of agreement, -18.8 to 7.0%) are clinically acceptable. Calculated cardiac output for all recirculation fractions was accurate but imprecise (RecirculationAUC: bias 0.56 l/min; limits of agreement, -2.27 to 3.4 l/min; and RecirculationFLOW: bias 0.48 l/min; limits of agreement, -2.22 to 3.19 l/min). Recirculation fraction increased bias and decreased precision. CONCLUSIONS Adapted thermodilution for VV-ECMO allows simultaneous measurement of recirculation fraction and cardiac output and may help optimize patient management with severe respiratory failure. EDITOR’S PERSPECTIVE
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Elia J Stanger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp D Fried
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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13
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Douflé G, Dragoi L, Morales Castro D, Sato K, Donker DW, Aissaoui N, Fan E, Schaubroeck H, Price S, Fraser JF, Combes A. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med 2024; 50:632-645. [PMID: 38598123 DOI: 10.1007/s00134-024-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Nadia Aissaoui
- Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
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14
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Charbit J, Courvalin E, Dagod G, Laumon T, Hammani S, Molinari N, Capdevila X. PCO 2 Gradient Between Inlet and Outlet Blood of Extracorporeal Respiratory Support Is a Reliable Marker of CO 2 Elimination. ASAIO J 2024; 70:417-426. [PMID: 38127592 DOI: 10.1097/mat.0000000000002122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Our objective was to assess the relationship between the pre-/post-oxygenator gradient of the partial pressure of carbon dioxide (∆ EC PCO 2 ; dissolved form) and CO 2 elimination under extracorporeal respiratory support. All patients who were treated with veno-venous extracorporeal membrane oxygenation and high-flow extracorporeal CO 2 removal in our intensive care unit over 18 months were included. Pre-/post-oxygenator blood gases were collected every 12 h and CO 2 elimination was calculated for each pair of samples (pre-/post-oxygenator total carbon dioxide content in blood [ ct CO 2 ] × pump flow [extracorporeal pump flow {Q EC }]). The relationship between ∆ EC PCO 2 and CO 2 elimination, as well as the origin of CO 2 removed. Eighteen patients were analyzed (24 oxygenators and 293 datasets). Each additional unit of ∆ EC PCO 2 × Q EC was associated with an increase in CO 2 elimination of 5.2 ml (95% confidence interval [CI], 4.7-5.6 ml; p < 0.001). Each reduction of 1 ml STPD/dl of CO 2 across the oxygenator was associated with a reduction of 0.63 ml STPD/dl (95% CI, 0.60-0.66) of CO 2 combined with water, 0.08 ml STPD/dl (95% CI, 0.07-0.09) of dissolved CO 2 , and 0.29 ml STPD/dl (95% CI, 0.27-0.31) of CO 2 in erythrocytes. The pre-/post-oxygenator PCO 2 gradient under extracorporeal respiratory support is thus linearly associated with CO 2 elimination; however, most of the CO 2 removed comes from combined CO 2 in plasma, generating bicarbonate.
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Affiliation(s)
- Jonathan Charbit
- From the Trauma and Polyvalent Critical Care Unit, Montpellier University Hospital, Montpellier, France
- institut Desbrest d'épidémiologie et de santé publique, institut national de la santé et de la recherche médicale, University of Montpellier, Montpellier University Hospital, Montpellier, France
| | - Elie Courvalin
- From the Trauma and Polyvalent Critical Care Unit, Montpellier University Hospital, Montpellier, France
| | - Geoffrey Dagod
- From the Trauma and Polyvalent Critical Care Unit, Montpellier University Hospital, Montpellier, France
| | - Thomas Laumon
- From the Trauma and Polyvalent Critical Care Unit, Montpellier University Hospital, Montpellier, France
| | - Samy Hammani
- From the Trauma and Polyvalent Critical Care Unit, Montpellier University Hospital, Montpellier, France
| | - Nicolas Molinari
- institut Desbrest d'épidémiologie et de santé publique, institut national de la santé et de la recherche médicale, University of Montpellier, Montpellier University Hospital, Montpellier, France
| | - Xavier Capdevila
- From the Trauma and Polyvalent Critical Care Unit, Montpellier University Hospital, Montpellier, France
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15
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Mazzeffi M, Gutsche J. Thermodilution-derived Recirculation and Cardiac Output Measurement during Veno-venous Extracorporeal Membrane Oxygenation: Do We Need More Bells and Whistles? Anesthesiology 2024; 140:887-889. [PMID: 38592358 DOI: 10.1097/aln.0000000000004930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Michael Mazzeffi
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virginia
| | - Jacob Gutsche
- Penn Perelman School of Medicine, Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania
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16
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Bagate F, Masi P, Boukantar M, Radu C, Saiydoun G, Fiore A, Chiaroni PM, Teiger E, Folliguet T, Gallet R, Mekontso Dessap A. Refractory cor pulmonale under extracorporeal membrane oxygenation for acute respiratory distress syndrome: the role of conversion to veno-pulmonary arterial assist-a case series. Front Med (Lausanne) 2024; 11:1348077. [PMID: 38725464 PMCID: PMC11079173 DOI: 10.3389/fmed.2024.1348077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/05/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Pulmonary vascular dysfunction during severe acute respiratory distress syndrome (ARDS) may lead to right ventricle (RV) dysfunction and acute cor pulmonale (ACP). The occurrence/persistence of ACP despite conventional extracorporeal membrane oxygenation (ECMO) is a challenging situation. We explored the usefulness of a specific dual-lumen cannula that bypasses the RV, and on which a veno-pulmonary arterial assist (V-P ECMO) was mounted, in ARDS patients. Methods We report a case-series of ARDS patients put on conventional veno-arterial or veno-venous ECMO and presented refractory ACP as an indication for a reconfiguration to V-P ECMO using the ProtekDuo cannula. The primary endpoint was the mitigation of RV and pulmonary vascular dysfunction as assessed by the change in end-diastolic RV/left ventricle (LV) surface ratio. Results Six patients had their conventional ECMO reconfigured to V-P ECMO to treat refractory ACP. There was a decrease in end-diastolic RV/LV surface ratio, as well as end-systolic LV eccentricity index, and lactatemia immediately after V-P ECMO initiation. The resolution of refractory ACP was immediately achieved in four of our six (66%) patients. The V-P ECMO was weaned after a median of 26 [8-93] days after implantation. All but one patient were discharged home. We detected one case of severe hemolysis with V-P ECMO and two suspected cases of right-sided infective endocarditis. Conclusion V-P ECMO is useful to mitigate RV overload and to improve hemodynamics in case of refractory ACP despite conventional ECMO.
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Affiliation(s)
- François Bagate
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
| | - Paul Masi
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
| | - Madjid Boukantar
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
| | - Costin Radu
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Gabriel Saiydoun
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Antonio Fiore
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | | | - Emmanuel Teiger
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
| | - Thierry Folliguet
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Romain Gallet
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
- U955-IMRB, Equipe 03, Inserm, Univ Paris Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (EnVA), Maisons-Alfort, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
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17
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Tomarchio E, Momigliano F, Giosa L, Collins PD, Barrett NA, Camporota L. The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians. Perfusion 2024; 39:49S-65S. [PMID: 38654449 DOI: 10.1177/02676591241238156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
During veno-venous extracorporeal membrane oxygenation (V-V ECMO), blood is drained from the central venous circulation to be oxygenated and decarbonated by an artificial lung. It is then reinfused into the right heart and pulmonary circulation where further gas-exchange occurs. Each of these steps is characterized by a peculiar physiology that this manuscript analyses, with the aim of providing bedside tools for clinical care: we begin by describing the factors that affect the efficiency of blood drainage, such as patient and cannulae position, fluid status, cardiac output and ventilatory strategies. We then dig into the complexity of extracorporeal gas-exchange, with particular reference to the effects of extracorporeal blood-flow (ECBF), fraction of delivered oxygen (FdO2) and sweep gas-flow (SGF) on oxygenation and decarbonation. Subsequently, we focus on the reinfusion of arterialized blood into the right heart, highlighting the effects on recirculation and, more importantly, on right ventricular function. The importance and challenges of haemodynamic monitoring during V-V ECMO are also analysed. Finally, we detail the interdependence between extracorporeal circulation, native lung function and mechanical ventilation in providing adequate arterial blood gases while allowing lung rest. In the absence of evidence-based strategies to care for this particular group of patients, clinical practice is underpinned by a sound knowledge of the intricate physiology of V-V ECMO.
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Affiliation(s)
- Emilia Tomarchio
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Francesca Momigliano
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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18
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Moury PH, Béhouche A, Bailly S, Durand Z, Dessertaine G, Pollet A, Jaber S, Verges S, Albaladejo P. Diaphragm thickness modifications and associated factors during VA-ECMO for a cardiogenic shock: a cohort study. Ann Intensive Care 2024; 14:38. [PMID: 38457010 PMCID: PMC10923772 DOI: 10.1186/s13613-024-01264-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/16/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The incidence, causes and impact of diaphragm thickness evolution in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock are unknown. Our study investigates its evolution during the first week of VA-ECMO and its relationship with sweep gas flow settings. METHODS We conducted a prospective monocentric observational study in a 12-bed ICU in France, enrolling patients on the day of the VA-ECMO implantation. The diaphragm thickness and the diaphragm thickening fraction (as index of contractile activity, dTF; dTF < 20% defined a low contractile activity) were daily measured for one week using ultrasound. Factors associated with diaphragm thickness evolution (categorized as increased, stable, or atrophic based on > 10% modification from baseline to the last measurement), early extubation role (< day4), and patients outcome at 60 days were investigated. Changes in diaphragm thickness, the primary endpoint, was analysed using a mixed-effect linear model (MLM). RESULTS Of the 29 included patients, seven (23%) presented diaphragm atrophy, 18 remained stable (60%) and 4 exhibited an increase (17%). None of the 13 early-extubated patients experienced diaphragm atrophy, while 7 (46%) presented a decrease when extubated later (p-value = 0.008). Diaphragm thickness changes were not associated with the dTF (p-value = 0.13) but with sweep gas flow (Beta = - 3; Confidence Interval at 95% (CI) [- 4.8; - 1.2]. p-value = 0.001) and pH (Beta = - 2; CI [- 2.9; - 1]. p-value < 0.001) in MLM. The dTF remained low (< 20%) in 20 patients (69%) at the study's end and was associated with sweep gas flow evolution in MLM (Beta = - 2.8; 95% CI [- 5.2; - 0.5], p-value = 0.017). Odds ratio of death at 60 days in case of diaphragm atrophy by day 7 was 8.50 ([1.4-74], p = 0.029). CONCLUSION In our study, diaphragm thickness evolution was frequent and not associated with the diaphragm thickening fraction. Diaphragm was preserved from atrophy in case of early extubation with ongoing VA-ECMO assistance. Metabolic disorders resulting from organ failures and sweep gas flow were linked with diaphragm thickness evolution. Preserved diaphragm thickness in VA-ECMO survivors emphasizes the importance of diaphragm-protective strategies, including meticulous sweep gas flow titration.
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Affiliation(s)
- Pierre-Henri Moury
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France.
- Univ. Grenoble Alpes, Inserm, Grenoble Alpes University Hospital, HP2 Laboratory, Grenoble, France.
| | - Alexandre Béhouche
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
| | - Sébastien Bailly
- Univ. Grenoble Alpes, Inserm, Grenoble Alpes University Hospital, HP2 Laboratory, Grenoble, France
| | - Zoé Durand
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
| | | | - Angelina Pollet
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Anaesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Samuel Verges
- Univ. Grenoble Alpes, Inserm, Grenoble Alpes University Hospital, HP2 Laboratory, Grenoble, France
| | - Pierre Albaladejo
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
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19
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Huai J, Ye X. Lung Ultrasound Evaluation of Aeration Changes in Response to Prone Positioning in Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: An Observational Study. Cureus 2024; 16:e55554. [PMID: 38576649 PMCID: PMC10993767 DOI: 10.7759/cureus.55554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Prone positioning (PP) has been proven to be a beneficial approach in enhancing survival outcomes for patients with severe acute respiratory distress syndrome (ARDS) who need venovenous extracorporeal membrane oxygenation (V-V ECMO) support. The study utilized bedside lung ultrasound (LUS) to evaluate changes in lung aeration caused by PP in ARDS patients receiving V-V ECMO. METHODS This retrospective single-center study involved adult ARDS patients requiring V-V ECMO. The assessment of LUS involved examining specific dorsal lung regions, encompassing 16 areas, during three pre-defined time points: baseline (10 minutes prior), three-hour PP positioning, and 10-minute post-supine repositioning, all within the initial three days. Based on the oxygenation response to PP, patients were categorized into responder and non-responder groups. The primary outcome was LUS score changes during the initial three-day period. Secondary outcomes examined the impact of PP on the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) (P/F) ratio, V-V ECMO weaning success, length of ICU stay, and hospital survival. RESULTS Among the enrolled patients (27 in total), 16 were responders and 11 were non-responders. In the responder group, the global LUS score underwent a significant reduction from 26.38 ± 4.965 at baseline to 20.75 ± 3.337 (p < 0.001) after the first PP session, which further decreased to 15.94 ± 2.816 (p< 0.001) after three days. However, no significant differences were observed among PP non-responders. The oxygenation reaction yielded comparable results. There was a significant correlation between the duration of daily PP and the reduction in global LUS score among PP responders (r = -0.855, p < 0.001). In cases where the global LUS score decreased by > 7.5 after three days of PP, the area under the receiver operating characteristic curve (AUROC) for predicting ECMO weaning success was 0.815, while it was 0.761 for predicting hospital survival. CONCLUSION LUS has the potential to predict the response to PP and evaluate the prognosis of ARDS patients with V-V ECMO, although more studies are demanded in the future.
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Affiliation(s)
- Jiaping Huai
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, CHN
| | - Xiaohua Ye
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, CHN
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20
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Patel YJ, Gannon WD, Francois SA, Stokes JW, Tipograf Y, Landsperger JS, Semler MW, Casey JD, Rice TW, Bacchetta M. Extracorporeal membrane oxygenation circuits in parallel for refractory hypoxemia in patients with COVID-19. J Thorac Cardiovasc Surg 2024; 167:746-754.e1. [PMID: 36270862 PMCID: PMC9463075 DOI: 10.1016/j.jtcvs.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Refractory hypoxemia can occur in patients with acute respiratory distress syndrome from COVID-19 despite support with venovenous (VV) extracorporeal membrane oxygenation (ECMO). Parallel ECMO circuits can be used to increase physiologic support. We report our clinical experience using ECMO circuits in parallel for select patients with persistent severe hypoxemia despite the use of a single ECMO circuit. METHODS We performed a retrospective cohort study of all patients with COVID-19-related acute respiratory distress syndrome who received VV-ECMO with an additional circuit in parallel at Vanderbilt University Medical Center between March 1, 2020, and March 1, 2022. We report demographic characteristics and clinical characteristics including ECMO settings, mechanical ventilator settings, use of adjunctive therapies, and arterial blood gas results after initial cannulation, before and after receipt of a second ECMO circuit in parallel, and before removal of the circuit in parallel, and outcomes. RESULTS Of 84 patients with COVID-19 who received VV-ECMO during the study period, 22 patients (26.2%) received a circuit in parallel. The median duration of ECMO was 40.0 days (interquartile range, 31.6-53.1 days), of which 19.0 days (interquartile range, 13.0-33.0 days) were spent with a circuit in parallel. Of the 22 patients who received a circuit in parallel, 16 (72.7%) survived to hospital discharge and 6 (27.3%) died before discharge. CONCLUSIONS In select patients, the additional use of an ECMO circuit in parallel can increase ECMO blood flow and improve oxygenation while allowing for lung-protective mechanical ventilation and excellent outcomes.
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Affiliation(s)
- Yatrik J Patel
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Whitney D Gannon
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Sean A Francois
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - John W Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Yuliya Tipograf
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Janna S Landsperger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tenn.
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21
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Sawka DM, Su Y, Monteagudo J, Zenit R. Fluid Flow Analysis of Neonatal Dual-Lumen Cannulas for Venovenous Extracorporeal Membrane Oxygenation. J Biomech Eng 2024; 146:021008. [PMID: 38071491 DOI: 10.1115/1.4064212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Indexed: 12/21/2023]
Abstract
Hemolysis persists as a common and serious problem for neonatal patients on extracorporeal membrane oxygenation (ECMO). Since the cannula within the ECMO circuit is associated with hemolysis-inducing shear stresses, real-world internal fluid flow measurements are urgently needed to understand the mechanism and confirm computational estimates. This study appears to be the first experimental study of fluid flow inside commercial ECMO dual-lumen cannulas (DLCs) and first particle image velocimetry (PIV) visualization inside a complicated medical device. The internal geometries of four different opaque neonatal DLCs, both atrial and bicaval positioning geometries each sized 13 Fr and 16 Fr, were replicated by three-dimensional printing clear lumen scaled-up models, which were integrated in a circuit with appropriate ECMO flow parameters. PIV was then used to visualize two-dimensional fluid flow in a single cross section within the models. An empirical model accounting for shear stress and exposure time was used to compare the maximum expected level of hemolysis through each model. The maximum measured peak shear stress recorded was 16±2 Pa in the top arterial bicaval 13 Fr model. The atrial and 16 Fr cannula models never produced greater single-pass peak shear stress or hemolysis than the bicaval and 13 Fr models, respectively, and no difference was found in hemolysis at two different flow rates. After 5 days of flow, small DLC-induced hemolysis values for a single pass through each cannula were modeled to linearly accumulate and caused the most severe hemolysis in the bicaval 13 Fr DLC. Engineering and clinical solutions to improve cannula safety are proposed.
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Affiliation(s)
- Danielle M Sawka
- The Warren Alpert Medical School of Brown University, 70 Ship Street Box G-9486, Providence, RI 02903
| | - Yunxing Su
- Center for Fluid Mechanics, Brown University School of Engineering, 345 Brook St, Providence, RI 02912
| | - Julie Monteagudo
- Pediatric Surgery, The Warren Alpert Medical School of Brown University, 70 Ship Street Box G-M1, Providence, RI 02903
| | - Roberto Zenit
- Center for Fluid Mechanics, Brown University School of Engineering, 345 Brook St, Providence, RI 02912
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22
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Collins PD, Giosa L, Camporota L, Barrett NA. State of the art: Monitoring of the respiratory system during veno-venous extracorporeal membrane oxygenation. Perfusion 2024; 39:7-30. [PMID: 38131204 DOI: 10.1177/02676591231210461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Monitoring the patient receiving veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging due to the complex physiological interplay between native and membrane lung. Understanding these interactions is essential to understand the utility and limitations of different approaches to respiratory monitoring during ECMO. We present a summary of the underlying physiology of native and membrane lung gas exchange and describe different tools for titrating and monitoring gas exchange during ECMO. However, the most important role of VV ECMO in severe respiratory failure is as a means of avoiding further ergotrauma. Although optimal respiratory management during ECMO has not been defined, over the last decade there have been advances in multimodal respiratory assessment which have the potential to guide care. We describe a combination of imaging, ventilator-derived or invasive lung mechanic assessments as a means to individualise management during ECMO.
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Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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23
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Worku E, Brodie D, Shekar K. Weaning From Venovenous Extracorporeal Membrane Oxygenation-The Regensburg Way? Crit Care Med 2024; 52:147-150. [PMID: 38095522 DOI: 10.1097/ccm.0000000000006077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Elliott Worku
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
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24
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Zhang H, Xu Y, Huang X, Yang S, Li R, Wu Y, Zou X, Yu Y, Shang Y. Extracorporeal membrane oxygenation in adult patients with sepsis and septic shock: Why, how, when, and for whom. JOURNAL OF INTENSIVE MEDICINE 2024; 4:62-72. [PMID: 38263962 PMCID: PMC10800772 DOI: 10.1016/j.jointm.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 01/25/2024]
Abstract
Sepsis and septic shock remain the leading causes of death in intensive care units. Some patients with sepsis fail to respond to routine treatment and rapidly progress to refractory respiratory and circulatory failure, necessitating extracorporeal membrane oxygenation (ECMO). However, the role of ECMO in adult patients with sepsis has not been fully established. According to existing studies, ECMO may be a viable salvage therapy in carefully selected adult patients with sepsis. The choice of venovenous, venoarterial, or hybrid ECMO modes is primarily determined by the patient's oxygenation and hemodynamics (distributive shock with preserved cardiac output, septic cardiomyopathy (left, right, or biventricular heart failure), or right ventricular failure caused by acute respiratory distress syndrome). Veno-venous ECMO can be used in patients with sepsis and severe acute respiratory distress syndrome when conventional mechanical ventilation fails, and early application of veno-arterial ECMO in patients with sepsis-induced refractory cardiogenic shock may be critical in improving their chances of survival. When ECMO is indicated, the choice of an appropriate mode and determination of the optimal timing of initiation and weaning are critical, particularly in an experienced ECMO center. Furthermore, some special issues, such as ECMO flow, anticoagulation, and antibiotic therapy, should be noted during the management of ECMO support.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Youdong Xu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Xin Huang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Shunyin Yang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
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25
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Joyce CJ, Udy A, Burrell A, Brown A. Therapeutic Hypothermia for Refractory Hypoxemia on Venovenous Extracorporeal Membrane Oxygenation: An In Silico Study. ASAIO J 2023; 69:1031-1038. [PMID: 37532254 DOI: 10.1097/mat.0000000000002020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
Patients with respiratory failure may remain hypoxemic despite treatment with venovenous extracorporeal membrane oxygenation (VV-ECMO). Therapeutic hypothermia is a potential treatment for such hypoxia as it reduces cardiac output ( ) and oxygen consumption. We modified a previously published mathematical model of gas exchange to investigate the effects of hypothermia during VV-ECMO. Partial pressures were expressed as measured at 37°C (α-stat). The effect of hypothermia on gas exchange was examined in four clinical scenarios of hypoxemia on VV-ECMO, each with different physiological derangements. All scenarios had arterial partial pressure of oxygen (PaO 2 ) ≤ 46 mm Hg and arterial oxygen saturation of hemoglobin (SaO 2 ) ≤ 81%. Three had high with low extracorporeal blood flow to ratio ( ). The problem in the fourth scenario was recirculation, with normal . Cooling to 33°C increased SaO 2 to > 89% and PaO 2 to > 50 mm Hg in all scenarios. Mixed venous oxygen saturation of hemoglobin as % ( ) increased to > 70% and mixed venous partial pressure of oxygen in mm Hg ( ) increased to > 34 mm Hg in scenarios with low . In the scenario with high recirculation, and increased, but to < 50% and < 27 mm Hg, respectively. This in silico study predicted cooling to 33°C will improve oxygenation in refractory hypoxemia on VV-ECMO, but the improvement will be less when the problem is recirculation.
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Affiliation(s)
- Christopher J Joyce
- From the Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Aidan Burrell
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Alastair Brown
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
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26
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Naik R, Avula S, Palleti SK, Gummadi J, Ramachandran R, Chandramohan D, Dhillon G, Gill AS, Paiwal K, Shaik B, Balachandran M, Patel B, Gurugubelli S, Mariswamy Arun Kumar AK, Nanjundappa A, Bellamkonda M, Rathi K, Sakhamuri PL, Nassar M, Bali A. From Emergence to Endemicity: A Comprehensive Review of COVID-19. Cureus 2023; 15:e48046. [PMID: 37916248 PMCID: PMC10617653 DOI: 10.7759/cureus.48046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/03/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), later renamed coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, in early December 2019. Initially, the China office of the World Health Organization was informed of numerous cases of pneumonia of unidentified etiology in Wuhan, Hubei Province at the end of 2019. This would subsequently result in a global pandemic with millions of confirmed cases of COVID-19 and millions of deaths reported to the WHO. We have analyzed most of the data published since the beginning of the pandemic to compile this comprehensive review of SARS-CoV-2. We looked at the core ideas, such as the etiology, epidemiology, pathogenesis, clinical symptoms, diagnostics, histopathologic findings, consequences, therapies, and vaccines. We have also included the long-term effects and myths associated with some therapeutics of COVID-19. This study presents a comprehensive assessment of the SARS-CoV-2 virology, vaccines, medicines, and significant variants identified during the course of the pandemic. Our review article is intended to provide medical practitioners with a better understanding of the fundamental sciences, clinical treatment, and prevention of COVID-19. As of May 2023, this paper contains the most recent data made accessible.
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Affiliation(s)
- Roopa Naik
- Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
- Internal Medicine/Hospital Medicine, Geisinger Health System, Wilkes Barre, USA
| | - Sreekant Avula
- Diabetes, Endocrinology, and Metabolism, University of Minnesota, Minneapolis, USA
| | - Sujith K Palleti
- Nephrology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jyotsna Gummadi
- Internal Medicine, MedStar Franklin Square Medical Center, Baltimore, USA
| | | | | | - Gagandeep Dhillon
- Physician Executive MBA, University of Tennessee, Knoxville, USA
- Internal Medicine, University of Maryland Baltimore Washington Medical Center, Glen Burnie, USA
| | | | - Kapil Paiwal
- Oral & Maxillofacial Pathology, Daswani Dental College & Research Center, Kota, IND
| | - Bushra Shaik
- Internal Medicine, Onslow Memorial Hospital, Jacksonville, USA
| | | | - Bhumika Patel
- Oral Medicine and Radiology, Howard University, Washington, D.C., USA
| | | | | | | | - Mahita Bellamkonda
- Hospital Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Kanika Rathi
- Internal Medicine, University of Florida, Gainesville, USA
| | | | - Mahmoud Nassar
- Endocrinology, Diabetes, and Metabolism, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Atul Bali
- Internal Medicine/Nephrology, Geisinger Medical Center, Danville, USA
- Internal Medicine/Nephrology, Geisinger Health System, Wilkes-Barre, USA
- Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
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27
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Szułdrzyński K, Kowalewski M, Jankowski M, Staromłyński J, Prokop J, Pasierski M, Chudziński K, Drobiński D, Martucci G, Lorusso R, Wierzba W, Zaczyński A, Król Z, Suwalski P. Effects of adding the second drainage cannula in severely hypoxemic patients supported with VV ECMO due to COVID-19-associated ARDS. Artif Organs 2023; 47:1622-1631. [PMID: 37218216 DOI: 10.1111/aor.14591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a recognized method of support in patients with severe and refractory acute respiratory distress syndrome (ARDS) caused by SARS-CoV-2 infection. While veno-venous (VV) ECMO is the most common type, some patients with severe hypoxemia may require modifications to the ECMO circuit. In this study, we aimed to investigate the effects of adding a second drainage cannula to the circuit in patients with refractory hypoxemia, on their gas exchange, mechanical ventilation, ECMO settings, and clinical outcomes. METHODS We conducted an observational retrospective study based on a single-center institutional registry including all consecutive cases of COVID-19 patients requiring ECMO admitted to the Centre of Extracorporeal Therapies in Warsaw between March 1, 2020 and March 1, 2022. We selected patients who had an additional drainage cannula inserted. Changes in ECMO and ventilator settings, blood oxygenation, and hemodynamic parameters, as well as clinical outcomes were assessed. RESULTS Of 138 VV ECMO patients, 12 (9%) patients met the inclusion criteria. Ten patients (83%) were men, and mean age was 42.2 ± 6.8. An addition of drainage cannula resulted in a significant raise in ECMO blood flow (4.77 ± 0.44 to 5.94 ± 0.81 [L/min]; p = 0.001), and the ratio of ECMO blood flow to ECMO pump rotations per minute (RPM), whereas the raise in ECMO RPM alone was not statistically significant (3432 ± 258 to 3673 ± 340 [1/min]; p = 0.064). We observed a significant drop in ventilator FiO2 and a raise in PaO2 to FiO2 ratio, while blood lactates did not change significantly. Nine patients died in hospital, one was referred to lung transplantation center, two were discharged uneventfully. CONCLUSIONS The use of an additional drainage cannula in severe ARDS associated with COVID-19 allows for an increased ECMO blood flow and improved oxygenation. However, we observed no further improvement in lung-protective ventilation and poor survival.
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Affiliation(s)
- Konstanty Szułdrzyński
- Department of Anaesthesiology and Intensive Care, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Miłosz Jankowski
- Department of Anaesthesiology and Intensive Care, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Jakub Staromłyński
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Joanna Prokop
- Department of Anaesthesiology and Intensive Care, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Michał Pasierski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Kamil Chudziński
- Department of Anaesthesiology and Intensive Care, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Dominik Drobiński
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Waldemar Wierzba
- National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Artur Zaczyński
- National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Zbigniew Król
- National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Piotr Suwalski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Trieu NHK, Pham HM, Mai AT. Initial management of acute circulatory failure in amniotic fluid embolism: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023; 52:101288. [DOI: 10.1016/j.tacc.2023.101288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
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Omlor AJ, Caspari S, Omlor LS, Jungmann AM, Krawczyk M, Schmoll N, Mang S, Seiler F, Muellenbach RM, Bals R, Lepper PM. Comparison of Serial and Parallel Connections of Membrane Lungs against Refractory Hypoxemia in a Mock Circuit. MEMBRANES 2023; 13:809. [PMID: 37887981 PMCID: PMC10608735 DOI: 10.3390/membranes13100809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an important rescue therapy method for the treatment of severe hypoxic lung injury. In some cases, oxygen saturation and oxygen partial pressure in the arterial blood are low despite ECMO therapy. There are case reports in which patients with such instances of refractory hypoxemia received a second membrane lung, either in series or in parallel, to overcome the hypoxemia. It remains unclear whether the parallel or serial connection is more effective. Therefore, we used an improved version of our full-flow ECMO mock circuit to test this. The measurements were performed under conditions in which the membrane lungs were unable to completely oxygenate the blood. As a result, only the photometric pre- and post-oxygenator saturations, blood flow and hemoglobin concentration were required for the calculation of oxygen transfer rates. The results showed that for a pre-oxygenator saturation of 45% and a total blood flow of 10 L/min, the serial connection of two identical 5 L rated oxygenators is 17% more effective in terms of oxygen transfer than the parallel connection. Although the idea of using a second membrane lung if refractory hypoxia occurs is intriguing from a physiological point of view, due to the invasiveness of the solution, further investigations are needed before this should be used in a wider clinical setting.
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Affiliation(s)
- Albert J. Omlor
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Stefan Caspari
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Leonie S. Omlor
- Department of Anaesthesiology and Critical Care, University Hospital of Saarland, 66424 Homburg, Germany
| | - Anna M. Jungmann
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Marcin Krawczyk
- Department of Internal Medicine II, University Hospital of Saarland, 66424 Homburg, Germany
- Laboratory of Metabolic Liver Diseases, Department of General, Transplant and Liver Surgery, Centre for Preclinical Research, Medical University of Warsaw, 02091 Warsaw, Poland
| | - Nicole Schmoll
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Sebastian Mang
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
| | - Ralf M. Muellenbach
- Department of Anaesthesiology and Critical Care, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - Robert Bals
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI), 66123 Saarbrücken, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V—Pneumology, Allergology and Intensive Care Medicine, University Hospital of Saarland, 66424 Homburg, Germany
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Staudacher DL, Wengenmayer T, Schmidt M. Beta-blockers in refractory hypoxemia on venovenous extracorporeal membrane oxygenation: a double-edged sword. Crit Care 2023; 27:360. [PMID: 37730684 PMCID: PMC10510284 DOI: 10.1186/s13054-023-04648-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
- Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Matthieu Schmidt
- 1166-ICAN, Institute of Cardiometabolism and Nutrition, APHP, Hôpital Pitié- Salpêtrière, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Sorbonne Université, Paris, France
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Bachmann KF, Berger D, Moller PW. Interactions between extracorporeal support and the cardiopulmonary system. Front Physiol 2023; 14:1231016. [PMID: 37772062 PMCID: PMC10523013 DOI: 10.3389/fphys.2023.1231016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
This review describes the intricate physiological interactions involved in the application of extracorporeal therapy, with specific focus on cardiopulmonary relationships. Extracorporeal therapy significantly influences cardiovascular and pulmonary physiology, highlighting the necessity for clinicians to understand these interactions for improved patient care. Veno-arterial extracorporeal membrane oxygenation (veno-arterial ECMO) unloads the right ventricle and increases left ventricular (LV) afterload, potentially exacerbating LV failure and pulmonary edema. Veno-venous (VV) ECMO presents different challenges, where optimal device and ventilator settings remain unknown. Influences on right heart function and native gas exchange as well as end-expiratory lung volumes are important concepts that should be incorporated into daily practice. Future studies should not be limited to large clinical trials focused on mortality but rather address physiological questions to advance the understanding of extracorporeal therapies. This includes exploring optimal device and ventilator settings in VV ECMO, standardizing cardiopulmonary function monitoring strategies, and developing better strategies for device management throughout their use. In this regard, small human or animal studies and computational physiological modeling may contribute valuable insights into optimizing the management of extracorporeal therapies.
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Affiliation(s)
- Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Webb L, Burton L, Manchikalapati A, Prabhakaran P, Loberger JM, Richter RP. Cardiac dysfunction in severe pediatric acute respiratory distress syndrome: the right ventricle in search of the right therapy. Front Med (Lausanne) 2023; 10:1216538. [PMID: 37654664 PMCID: PMC10466806 DOI: 10.3389/fmed.2023.1216538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
Severe acute respiratory distress syndrome in children, or PARDS, carries a high risk of morbidity and mortality that is not fully explained by PARDS severity alone. Right ventricular (RV) dysfunction can be an insidious and often under-recognized complication of severe PARDS that may contribute to its untoward outcomes. Indeed, recent evidence suggest significantly worse outcomes in children who develop RV failure in their course of PARDS. However, in this narrative review, we highlight the dearth of evidence regarding the incidence of and risk factors for PARDS-associated RV dysfunction. While we wish to draw attention to the absence of available evidence that would inform recommendations around surveillance and treatment of RV dysfunction during severe PARDS, we leverage available evidence to glean insights into potentially helpful surveillance strategies and therapeutic approaches.
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Affiliation(s)
- Lece Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Luke Burton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ananya Manchikalapati
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Priya Prabhakaran
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeremy M. Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Robert P. Richter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
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Worku E, Schmidt M, Shekar K. Is It Time to Put Low-Flow Extracorporeal Carbon Dioxide Removal to REST? Crit Care Med 2023; 51:973-976. [PMID: 37318293 DOI: 10.1097/ccm.0000000000005889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
| | - Matthieu Schmidt
- Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Maxwell C, Forrest P. The role of ECMO support in airway procedures. BJA Educ 2023; 23:248-255. [PMID: 37389276 PMCID: PMC10300492 DOI: 10.1016/j.bjae.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 03/08/2023] [Indexed: 07/01/2023] Open
Affiliation(s)
- C. Maxwell
- Royal Prince Alfred Hospital, Sydney, Australia
| | - P. Forrest
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney University Medical School, Sydney, Australia
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Khanduja S, Kim J, Kang JK, Feng CY, Vogelsong MA, Geocadin RG, Whitman G, Cho SM. Hypoxic-Ischemic Brain Injury in ECMO: Pathophysiology, Neuromonitoring, and Therapeutic Opportunities. Cells 2023; 12:1546. [PMID: 37296666 PMCID: PMC10252448 DOI: 10.3390/cells12111546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), in conjunction with its life-saving benefits, carries a significant risk of acute brain injury (ABI). Hypoxic-ischemic brain injury (HIBI) is one of the most common types of ABI in ECMO patients. Various risk factors, such as history of hypertension, high day 1 lactate level, low pH, cannulation technique, large peri-cannulation PaCO2 drop (∆PaCO2), and early low pulse pressure, have been associated with the development of HIBI in ECMO patients. The pathogenic mechanisms of HIBI in ECMO are complex and multifactorial, attributing to the underlying pathology requiring initiation of ECMO and the risk of HIBI associated with ECMO itself. HIBI is likely to occur in the peri-cannulation or peri-decannulation time secondary to underlying refractory cardiopulmonary failure before or after ECMO. Current therapeutics target pathological mechanisms, cerebral hypoxia and ischemia, by employing targeted temperature management in the case of extracorporeal cardiopulmonary resuscitation (eCPR), and optimizing cerebral O2 saturations and cerebral perfusion. This review describes the pathophysiology, neuromonitoring, and therapeutic techniques to improve neurological outcomes in ECMO patients in order to prevent and minimize the morbidity of HIBI. Further studies aimed at standardizing the most relevant neuromonitoring techniques, optimizing cerebral perfusion, and minimizing the severity of HIBI once it occurs will improve long-term neurological outcomes in ECMO patients.
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Affiliation(s)
- Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Jiah Kim
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Cheng-Yuan Feng
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Melissa Ann Vogelsong
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Romergryko G. Geocadin
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
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Greiwe G, Flick M, Hapfelmeier A, Winkler MS, Nitzschke R, Frings D, Saugel B. Agreement between cardiac output measurements by pulse wave analysis using the Pressure Recording Analytical Method and transthoracic echocardiography in patients with veno-venous extracorporeal membrane oxygenation therapy: An observational method comparison. Eur J Anaesthesiol 2023; 40:436-441. [PMID: 37052059 DOI: 10.1097/eja.0000000000001828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Measuring cardiac output (CO) is important in patients treated with veno-venous extracorporeal membrane oxygenation (vvECMO) because vvECMO flow and CO need to be balanced. Uncalibrated pulse wave analysis with the Pressure Recording Analytical Method (PRAM) may be suitable to measure CO in patients with vvECMO therapy. OBJECTIVE To assess the agreement between CO measured by PRAM (PRAM-CO; test method) and CO measured by transthoracic echocardiography (TTE-CO; reference method). DESIGN A prospective observational method comparison study. SETTING The ICU of a German university hospital between March and December 2021. PATIENTS Thirty one adult patients with respiratory failure requiring vvECMO therapy: 29 of the 31 patients (94%) were treated for COVID-19 related respiratory failure. MAIN OUTCOME MEASURES PRAM-CO and TTE-CO were measured simultaneously at two time points in each patient with at least 20 min between measurements. A radial or femoral arterial catheter-derived blood pressure waveform was used for PRAM-CO measurements. TTE-CO measurements were conducted using the pulsed wave Doppler-derived velocity time integral of the left ventricular outflow tract (LVOT) and the corresponding LVOT diameter. PRAM-CO and TTE-CO were compared using Bland-Altman analysis and the percentage error (PE). We defined a PE of <30% as clinically acceptable. RESULTS Mean ± SD PRAM-CO was 6.86 ± 1.49 l min -1 and mean TTE-CO was 6.94 ± 1.58 l min -1 . The mean of the differences between PRAM-CO and TTE-CO was 0.09 ± 0.73 l min -1 with a lower 95% limit of agreement of -1.34 l min -1 and an upper 95% limit of agreement of 1.51 l min -1 . The PE was 21%. CONCLUSIONS The agreement between PRAM-CO and TTE-CO is clinically acceptable in adult patients with vvECMO therapy.
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Affiliation(s)
- Gillis Greiwe
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (GG, MF, RN, BS), the Institute of General Practice and Health Services Research, School of Medicine, Technical University of Munich, Munich, Germany (AH), the Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany (AH), the Department of Anesthesiology and Intensive Care, University Medical Center Göttingen, Göttingen, Germany (MSW), the Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (DF), the Outcomes Research Consortium, Cleveland, Ohio, USA (BS)
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Trombino S, Sole R, Curcio F, Cassano R. Polymeric Based Hydrogel Membranes for Biomedical Applications. MEMBRANES 2023; 13:576. [PMID: 37367780 DOI: 10.3390/membranes13060576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023]
Abstract
The development of biomedical applications is a transdisciplinary field that in recent years has involved researchers from chemistry, pharmacy, medicine, biology, biophysics, and biomechanical engineering. The fabrication of biomedical devices requires the use of biocompatible materials that do not damage living tissues and have some biomechanical characteristics. The use of polymeric membranes, as materials meeting the above-mentioned requirements, has become increasingly popular in recent years, with outstanding results in tissue engineering, for regeneration and replenishment of tissues constituting internal organs, in wound healing dressings, and in the realization of systems for diagnosis and therapy, through the controlled release of active substances. The biomedical application of hydrogel membranes has had little uptake in the past due to the toxicity of cross-linking agents and to the existing limitations regarding gelation under physiological conditions, but now it is proving to be a very promising field This review presents the important technological innovations that the use of membrane hydrogels has promoted, enabling the resolution of recurrent clinical problems, such as post-transplant rejection crises, haemorrhagic crises due to the adhesion of proteins, bacteria, and platelets on biomedical devices in contact with blood, and poor compliance of patients undergoing long-term drug therapies.
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Affiliation(s)
- Sonia Trombino
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Arcavacata, 87036 Rende, Italy
| | - Roberta Sole
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Arcavacata, 87036 Rende, Italy
| | - Federica Curcio
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Arcavacata, 87036 Rende, Italy
| | - Roberta Cassano
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Arcavacata, 87036 Rende, Italy
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Masi P, Bagate F, Tuffet S, Piscitelli M, Folliguet T, Razazi K, De Prost N, Carteaux G, Mekontso Dessap A. Dual titration of minute ventilation and sweep gas flow to control carbon dioxide variations in patients on venovenous extracorporeal membrane oxygenation. Ann Intensive Care 2023; 13:45. [PMID: 37225933 DOI: 10.1186/s13613-023-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The implantation of venovenous extracorporeal membrane oxygenation (VV-ECMO) support to manage severe acute respiratory distress syndrome generates large variations in carbon dioxide partial pressure (PaCO2) that are associated with intracranial bleeding. We assessed the feasibility and efficacy of a pragmatic protocol for progressive dual titration of sweep gas flow and minute ventilation after VV-ECMO implantation in order to limit significant PaCO2 variations. PATIENTS AND METHODS A protocol for dual titration of sweep gas flow and minute ventilation following VV-ECMO implantation was implemented in our unit in September 2020. In this single-centre retrospective before-after study, we included patients who required VV-ECMO from March, 2020 to May, 2021, which corresponds to two time periods: from March to August, 2020 (control group) and from September, 2020 to May, 2021 (protocol group). The primary endpoint was the mean absolute change in PaCO2 in consecutive arterial blood gases samples drawn over the first 12 h following VV-ECMO implantation. Secondary endpoints included large (> 25 mmHg) initial variations in PaCO2, intracranial bleedings and mortality in both groups. RESULTS Fifty-one patients required VV-ECMO in our unit during the study period, including 24 in the control group and 27 in the protocol group. The protocol was proved feasible. The 12-h mean absolute change in PaCO2 was significantly lower in patients of the protocol group as compared with their counterparts (7 mmHg [6-12] vs. 12 mmHg [6-24], p = 0.007). Patients of the protocol group experienced less large initial variations in PaCO2 immediately after ECMO implantation (7% vs. 29%, p = 0.04) and less intracranial bleeding (4% vs. 25%, p = 0.04). Mortality was similar in both groups (35% vs. 46%, p = 0.42). CONCLUSION Implementation of our protocol for dual titration of minute ventilation and sweep gas flow was feasible and associated with less initial PaCO2 variation than usual care. It was also associated with less intracranial bleeding.
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Affiliation(s)
- Paul Masi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France.
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France.
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France.
| | - François Bagate
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Mariantonietta Piscitelli
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Nicolas De Prost
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
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Usman AA, Cevasco M, Maybauer MO, Spelde AE, Olia S, Bermudez C, Ibrahim M, Szeto W, Vernick WJ, Gutsche JT. Oxygenated right ventricular assist device as part of veno-venopulmonary extracorporeal membrane oxygenation to support the right ventricle and pulmonary vasculature. J Cardiothorac Surg 2023; 18:134. [PMID: 37041646 PMCID: PMC10088623 DOI: 10.1186/s13019-023-02264-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
COVID-19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery.
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Affiliation(s)
- Asad Ali Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA.
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Marc O Maybauer
- Advanced Cardiac and Critical Care, Nazih Zuhdi Transplant Institute, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Hospital cardiac Arrest, Brisbane, Australia
| | - Audrey Elizabeth Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
| | - Salim Olia
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Ibrahim
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - William J Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
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Richley M, Rao R. Extracorporeal membrane oxygenation in pregnancy during the SARS-CoV-2 pandemic. Semin Fetal Neonatal Med 2023; 28:101435. [PMID: 37062669 PMCID: PMC10073081 DOI: 10.1016/j.siny.2023.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Affiliation(s)
- Michael Richley
- University of California, Los Angeles, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, USA
| | - Rashmi Rao
- University of California, Los Angeles, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, USA.
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Levy D, Desnos C, Lebreton G, Théry G, Pineton de Chambrun M, Leprince P, Hammoudi N, Schmidt M, Combes A, Hékimian G. Early Reversal of Right Ventricular Dysfunction after Venovenous Extracorporeal Membrane Oxygenation in Patients with COVID-19 Pneumonia. Am J Respir Crit Care Med 2023; 207:784-787. [PMID: 36459095 PMCID: PMC10037471 DOI: 10.1164/rccm.202208-1486le] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- David Levy
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation
| | - Cyrielle Desnos
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Chirurgie Cardiaque et thoracique, Institut de Cardiologie, and
| | - Guillaume Théry
- Service de Médecine Intensive-Réanimation
- Service de Médecine Intensive-Réanimation, Hôpital Universitaire de Reims, Reims, France; and
| | - Marc Pineton de Chambrun
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation
- Service de Médecine Interne 2, Centre de référence Lupus Systémique, SAPL et Autres Maladies Auto-immunes et Systémiques Rares, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Pascal Leprince
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Chirurgie Cardiaque et thoracique, Institut de Cardiologie, and
| | - Nadjib Hammoudi
- ACTION Study Group, INSERM UMR_S 1166 and Hôpital Pitié-Salpêtrière (AP-HP), Boulevard de l'hôpital, Sorbonne Université, Paris, France
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation
| | - Guillaume Hékimian
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation
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Shoni M, Lazar S, Jackson A, Tonetti MK, Horak J, Gutsche J, Augoustides JG, Marchant BE, Fernando RJ, Jelly CA, Gallo PD, Mazzeffi MA. Parallel Venovenous Extracorporeal Membrane Oxygenation Circuits for Refractory Hypoxemia in a Super-Super-Obese Patient. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00176-3. [PMID: 37028990 DOI: 10.1053/j.jvca.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Melina Shoni
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sofiane Lazar
- Department of Anesthesiology and Perioperative Medicine, Jefferson University Hospital, Philadelphia, PA
| | - Andrea Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mary Kate Tonetti
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bryan E Marchant
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest University School of Medicine, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Winston Salem, NC.
| | - Christina Anne Jelly
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Paul D Gallo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA
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43
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Extracorporeal Membrane Oxygenation During Pregnancy. Clin Obstet Gynecol 2023; 66:151-162. [PMID: 36044634 DOI: 10.1097/grf.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.
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Abstract
Extracorporeal membrane oxygenation (ECMO) can be delivered in veno-arterial (VA) and veno-venous (VV) configurations based on the cannulation strategy. VA and VV ECMO are delivered primarily for haemodynamic and respiratory support in patients with severe heart and lung failure, respectively. The Fick principle describes the relationship between blood flow and oxygen consumption - key parameters in the physiological management of extracorporeal support. This review will discuss the application of the Fick principle in: (i) recirculation in VV ECMO; (ii) the quantification of oxygen delivery (DO2) in VV ECMO and (iii) the quantification of transpulmonary blood flow and systemic arterial oxygen saturation in VA ECMO.
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Affiliation(s)
- Hoong Lim
- 156807Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
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45
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Alessandri F, Di Nardo M, Ramanathan K, Brodie D, MacLaren G. Extracorporeal membrane oxygenation for COVID-19-related acute respiratory distress syndrome: a narrative review. J Intensive Care 2023; 11:5. [PMID: 36755270 PMCID: PMC9907879 DOI: 10.1186/s40560-023-00654-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
A growing body of evidence supports the use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) refractory to maximal medical therapy. ARDS may develop in a proportion of patients hospitalized for coronavirus disease 2019 (COVID-19) and ECMO may be used to manage patients refractory to maximal medical therapy to mitigate the risk of ventilator-induced lung injury and provide lung rest while awaiting recovery. The mortality of COVID-19-related ARDS was variously reassessed during the pandemic. Veno-venous (VV) ECMO was the default choice to manage refractory respiratory failure; however, with concomitant severe right ventricular dysfunction, venoarterial (VA) ECMO or mechanical right ventricular assist devices with extracorporeal gas exchange (Oxy-RVAD) were also considered. ECMO has also been used to manage special populations such as pregnant women, pediatric patients affected by severe forms of COVID-19, and, in cases with persistent and seemingly irreversible respiratory failure, as a bridge to successful lung transplantation. In this narrative review, we outline and summarize the most recent evidence that has emerged on ECMO use in different patient populations with COVID-19-related ARDS.
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Affiliation(s)
- Francesco Alessandri
- grid.7841.aDepartment of General and Specialistic Surgery, Sapienza University of Rome, Rome, Italy
| | - Matteo Di Nardo
- grid.414125.70000 0001 0727 6809Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Kollengode Ramanathan
- grid.412106.00000 0004 0621 9599Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore
| | - Daniel Brodie
- grid.21729.3f0000000419368729Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY USA ,grid.239585.00000 0001 2285 2675Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore.
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46
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Extracorporeal Life Support for Trauma. Emerg Med Clin North Am 2023; 41:89-100. [DOI: 10.1016/j.emc.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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47
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Moreau A, Levy B, Annoni F, Lorusso R, Su F, Belliato M, Taccone FS. The use of induced hypothermia in extracorporeal membrane oxygenation: A narrative review. Resusc Plus 2023; 13:100360. [PMID: 36793940 PMCID: PMC9922920 DOI: 10.1016/j.resplu.2023.100360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/28/2022] [Accepted: 01/09/2023] [Indexed: 01/29/2023] Open
Abstract
Despite venovenous or venoarterial extracorporeal membrane oxygenation (ECMO) being increasingly used in patients with severe acute respiratory disease syndrome, severe cardiogenic shock, and refractory cardiac arrest, mortality rates still remain high mainly because of the severity of the underlying disease and the numerous complications associated with initiation of ECMO. Induced hypothermia might minimize several pathological pathways present in patients requiring ECMO; even though numerous studies conducted in the experimental setting have reported promising results, there are currently no recommendations suggesting the routine use of this therapy in patients requiring ECMO. In this review, we summarized the existing evidence on the use of induced hypothermia in patients requiring ECMO. Induced hypothermia was a feasible and relatively safe intervention in this setting; however, the effects on clinical outcomes remain uncertain. Whether controlled normothermia has an impact on these patients compared with no temperature control remains unknown. Further randomized controlled trials are required to better understand the role and impact of such therapy in patients requiring ECMO according to the underlying disease.
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Affiliation(s)
- Anthony Moreau
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France,INSERM U1116, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Fuhong Su
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mirko Belliato
- UOC AR 2-Anestesia e Rianimazione Cardiotoracica Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium,Corresponding author at: Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium.
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48
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Radu ER, Voicu SI, Thakur VK. Polymeric Membranes for Biomedical Applications. Polymers (Basel) 2023; 15:polym15030619. [PMID: 36771921 PMCID: PMC9919920 DOI: 10.3390/polym15030619] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/16/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
Polymeric membranes are selective materials used in a wide range of applications that require separation processes, from water filtration and purification to industrial separations. Because of these materials' remarkable properties, namely, selectivity, membranes are also used in a wide range of biomedical applications that require separations. Considering the fact that most organs (apart from the heart and brain) have separation processes associated with the physiological function (kidneys, lungs, intestines, stomach, etc.), technological solutions have been developed to replace the function of these organs with the help of polymer membranes. This review presents the main biomedical applications of polymer membranes, such as hemodialysis (for chronic kidney disease), membrane-based artificial oxygenators (for artificial lung), artificial liver, artificial pancreas, and membranes for osseointegration and drug delivery systems based on membranes.
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Affiliation(s)
- Elena Ruxandra Radu
- Department of Analytical Chemistry and Environmental Engineering, University Politehnica of Bucharest, 011061 Bucharest, Romania
- Advanced Polymers Materials Group, University Politehnica of Bucharest, 011061 Bucharest, Romania
| | - Stefan Ioan Voicu
- Department of Analytical Chemistry and Environmental Engineering, University Politehnica of Bucharest, 011061 Bucharest, Romania
- Advanced Polymers Materials Group, University Politehnica of Bucharest, 011061 Bucharest, Romania
- Correspondence: (S.I.V.); (V.K.T.)
| | - Vijay Kumar Thakur
- Biorefining and Advanced Materials Research Center, Scotland’s Rural College (SRUC), Kings Buildings, Edinburgh EH9 3JG, UK
- School of Engineering, University of Petroleum & Energy Studies (UPES), Dehradun 248007, Uttarakhand, India
- Centre for Research & Development, Chandigarh University, Mohali 140413, Punjab, India
- Correspondence: (S.I.V.); (V.K.T.)
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Wieruszewski PM, Ortoleva JP, Cormican DS, Seelhammer TG. Extracorporeal Membrane Oxygenation in Acute Respiratory Failure. Pulm Ther 2023; 9:109-126. [PMID: 36670314 PMCID: PMC9859746 DOI: 10.1007/s41030-023-00214-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a form of mechanical life support that provides full respiratory bypass in patients with severe respiratory failure as a bridge to recovery or lung transplantation. The use of ECMO for respiratory failure and capable centers offering ECMO has expanded over the years, increasing its availability. As VV-ECMO provides an artificial mechanism for oxygenation and decarboxylation of native blood, it allows for an environment in which safer mechanical ventilatory care may be provided, allowing for treatment and resolution of underlying respiratory pathologies. Landmark clinical trials have provided a framework for better understanding patient selection criteria, resource utilization, and outcomes associated with ECMO when applied in settings of refractory respiratory failure. Maintaining close vigilance and management of complications during ECMO as well as identifying strategies post-ECMO (e.g., recovery, transplantation, etc.), are critical to successful ECMO support. In this review, we examine considerations for candidate selection for VV-ECMO, review the evidence of utilizing VV-ECMO in respiratory failure, and provide practical considerations for managing respiratory ECMO patients, including complication identification and management, as well as assessing for the ability to separate from ECMO support and the procedures for decannulation.
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Affiliation(s)
- Patrick M. Wieruszewski
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA ,Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Jamel P. Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA USA
| | - Daniel S. Cormican
- Division of Cardiothoracic Anesthesiology, Allegheny General Hospital, Pittsburg, PA USA
| | - Troy G. Seelhammer
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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50
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The Impact of Recirculation on Extracorporeal Gas Exchange and Patient Oxygenation during Veno-Venous Extracorporeal Membrane Oxygenation-Results of an Observational Clinical Trial. J Clin Med 2023; 12:jcm12020416. [PMID: 36675344 PMCID: PMC9866780 DOI: 10.3390/jcm12020416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/17/2022] [Accepted: 12/27/2022] [Indexed: 01/07/2023] Open
Abstract
Background: Recirculation during veno-venous extracorporeal membrane oxygenation reduces extracorporeal oxygen exchange and patient oxygenation. To minimize recirculation and maximize oxygen delivery (DO2) the interaction of cannulation, ECMO flow and cardiac output requires careful consideration. We investigated this interaction in an observational trial. Methods: In 19 patients with acute respiratory distress syndrome and ECMO, we measured recirculation with the ultrasound dilution technique and calculated extracorporeal oxygen transfer (VO2), extracorporeal oxygen delivery (DO2) and patient oxygenation. To assess the impact of cardiac output (CO), we included CO measurement through pulse contour analysis. Results: In all patients, there was a median recirculation rate of approximately 14−16%, with a maximum rate of 58%. Recirculation rates >35% occurred in 13−14% of all cases. In contrast to decreasing extracorporeal gas exchange with increasing ECMO flow and recirculation, patient oxygenation increased with greater ECMO flows. High CO diminished recirculation by between 5−20%. Conclusions: Extracorporeal gas exchange masks the importance of DO2 and its effects on patients. We assume that increasing DO2 is more important than reduced VO2. A negative correlation of recirculation to CO adds to the complexity of this phenomenon. Patient oxygenation may be optimized with the direct measurement of recirculation.
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