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Kim WY, Jung SY, Kim JY, Chae G, Kim J, Joh JS, Park TY, Baek AR, Jegal Y, Chung CR, Lee J, Cho YJ, Park JH, Hwang JH, Song JW. ECMO is associated with decreased hospital mortality in COVID-19 ARDS. Sci Rep 2024; 14:14835. [PMID: 38937516 PMCID: PMC11211457 DOI: 10.1038/s41598-024-64949-x] [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: 01/08/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
This study determined whether compared to conventional mechanical ventilation (MV), extracorporeal membrane oxygenation (ECMO) is associated with decreased hospital mortality or fibrotic changes in patients with COVID-19 acute respiratory distress syndrome. A cohort of 72 patients treated with ECMO and 390 with conventional MV were analyzed (February 2020-December 2021). A target trial was emulated comparing the treatment strategies of initiating ECMO vs no ECMO within 7 days of MV in patients with a PaO2/FiO2 < 80 or a PaCO2 ≥ 60 mmHg. A total of 222 patients met the eligibility criteria for the emulated trial, among whom 42 initiated ECMO. ECMO was associated with a lower risk of hospital mortality (hazard ratio [HR], 0.56; 95% confidence interval [CI] 0.36-0.96). The risk was lower in patients who were younger (age < 70 years), had less comorbidities (Charlson comorbidity index < 2), underwent prone positioning before ECMO, and had driving pressures ≥ 15 cmH2O at inclusion. Furthermore, ECMO was associated with a lower risk of fibrotic changes (HR, 0.30; 95% CI 0.11-0.70). However, the finding was limited due to relatively small number of patients and differences in observability between the ECMO and conventional MV groups.
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Affiliation(s)
- Won-Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Jeong-Yeon Kim
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Ganghee Chae
- Department of Pulmonary and Critical Care Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Junghyun Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Joon-Sung Joh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Tae Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Borame Medical Center, Seoul, Republic of Korea
| | - Ae-Rin Baek
- Division of Allergy and Pulmonology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Yangjin Jegal
- Department of Pulmonary and Critical Care Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jung Hwa Hwang
- Department of Radiology, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Maitz T, Shah S, Gupta R, Goel A, Sreenivasan J, Hajra A, Vyas AV, Lavie CJ, Hawwa N, Lanier GM, Kapur NK. Pathophysiology, diagnosis and management of right ventricular failure: A state of the art review of mechanical support devices. Prog Cardiovasc Dis 2024:S0033-0620(24)00097-5. [PMID: 38944261 DOI: 10.1016/j.pcad.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The function of the right ventricle (RV) is to drive the forward flow of blood to the pulmonary system for oxygenation before returning to the left ventricle. Due to the thin myocardium of the RV, its function is easily affected by decreased preload, contractile motion abnormalities, or increased afterload. While various etiologies can lead to changes in RV structure and function, sudden changes in RV afterload can cause acute RV failure which is associated with high mortality. Early detection and diagnosis of RV failure is imperative for guiding initial medical management. Echocardiographic findings of reduced tricuspid annular plane systolic excursion (<1.7) and RV wall motion (RV S' <10 cm/s) are quantitatively supportive of RV systolic dysfunction. Medical management commonly involves utilizing diuretics or fluids to optimize RV preload, while correcting the underlying insult to RV function. When medical management alone is insufficient, mechanical circulatory support (MCS) may be necessary. However, the utility of MCS for isolated RV failure remains poorly understood. This review outlines the differences in flow rates, effects on hemodynamics, and advantages/disadvantages of MCS devices such as intra-aortic balloon pump, Impella, centrifugal-flow right ventricular assist devices, extracorporeal membrane oxygenation, and includes a detailed review of the latest clinical trials and studies analyzing the effects of MCS devices in acute RV failure.
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Affiliation(s)
- Theresa Maitz
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Swara Shah
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA.
| | - Akshay Goel
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | | | - Adrija Hajra
- Department of Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Apurva V Vyas
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Oshner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Nael Hawwa
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - Navin K Kapur
- Cardiovascular Center, Tufts Medical Center, Boston, MA, USA
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Sales G, Montrucchio G, Sanna V, Collino F, Fanelli V, Filippini C, Simonetti U, Bonetto C, Morscio M, Verderosa I, Urbino R, Brazzi L. Outcomes and Impact of Pre-ECMO Clinical Course in Severe COVID-19-Related ARDS Treated with VV-ECMO: Data from an Italian Referral ECMO Center. J Clin Med 2024; 13:3545. [PMID: 38930073 PMCID: PMC11204940 DOI: 10.3390/jcm13123545] [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: 04/21/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The efficacy of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as rescue therapy for refractory COVID-19-related ARDS (C-ARDS) is still debated. We describe the cohort of C-ARDS patients treated with VV-ECMO at our ECMO center, focusing on factors that may affect in-hospital mortality and describing the time course of lung mechanics to assess prognosis. Methods: We performed a prospective observational study in the intensive care unit at the "Città della Salute e della Scienza" University Hospital in Turin, Italy, between March 2020 and December 2021. Indications and management of ECMO followed the Extracorporeal Life Support Organization (ELSO) guidelines. Results: The 60-day in-hospital mortality was particularly high (85.4%). Non-survivor patients were more frequently treated with non-invasive ventilatory support and steroids before ECMO (95.1% vs. 57.1%, p = 0.018 and 73.2% vs. 28.6%, p = 0.033, respectively), while hypertension was the only pre-ECMO factor independently associated with in-hospital mortality (HR: 2.06, 95%CI: 1.06-4.00). High rates of bleeding (85.4%) and superinfections (91.7%) were recorded during ECMO, likely affecting the overall length of ECMO (18 days, IQR: 10-24) and the hospital stay (32 days, IQR: 24-47). Static lung compliance was lower in non-survivors (p = 0.031) and differed over time (p = 0.049), decreasing by 48% compared to initial values in non-survivors. Conclusions: Our data suggest the importance of considering NIS among the common ECMO eligibility criteria and changes in lung compliance during ECMO as a prognostic marker.
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Affiliation(s)
- Gabriele Sales
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Valentina Sanna
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
| | - Francesca Collino
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Claudia Filippini
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
| | - Umberto Simonetti
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Chiara Bonetto
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Monica Morscio
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Ivo Verderosa
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Rosario Urbino
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (G.M.); (L.B.)
- Department of Anesthesia, Intensive Care and Emergency, “Città Della Salute e Della Scienza” Hospital, 10126 Turin, Italy
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Lucchini A, Villa M, Giani M, Andreossi M, Alessandra V, Vigo V, Gatti S, Ferlicca D, Teggia Droghi M, Rezoagli E, Foti G, Pozzi M, Irccs San Gerardo Follow-Up Group. Long term outcome in patients treated with veno-venous extracorporeal membrane oxygenation: A prospective observational study. Intensive Crit Care Nurs 2024; 82:103631. [PMID: 38309144 DOI: 10.1016/j.iccn.2024.103631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Over the last few decades, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) support for severe respiratory failure has increased. AIM This study aimed to assess the long-term outcomes of patients treated with VV-ECMO for respiratory failure. METHODS We performed a single-centre prospective evaluation of patients on VV-ECMO who were successfully discharged from the intensive care unit of an Italian University Hospital between January 2018 and May 2021. The enrolled patients underwent follow-up evaluations at 6 and 12 months after ICU discharge. The follow-up team performed psychological and functional assessments using the following instruments: Hospital Anxiety and Depression Scale (HADS), Post-traumatic Stress Disorder Symptom Severity Scale (PTSS-10), Euro Quality Five Domains Five Levels (EQ-5L-5D), and 6-minute walk test. RESULTS We enrolled 33 patients who were evaluated at a follow-up clinic. The median patient age was 51 years (range: 45-58 years). The median duration of VV-ECMO support was 12 (9-19) days and the length of ICU stay was 23 (18-42) days. A HADS score higher than 14 was reported in 8 (24 %) and 7 (21 %) patients at the six- and twelve-month visit, respectively. PTSS-10 total score ≥ 35 points was present in three (9 %) and two (6 %) patients at the six- and twelve-month examination. The median EQ-5L-5D-VAS was respectively 80 (80-90) and 87.5 (70-95). The PTSS-10 score significantly decreased from six to 12 months in COVID-19 survivors (p = 0.024). CONCLUSIONS In this cohort of patients treated with VV-ECMO, cognitive and psychological outcomes were good and comparable to those of patients with Adult Respiratory Distress Syndrome (ARDS) managed without ECMO. IMPLICATIONS FOR CLINICAL PRACTICE The findings of this study confirm the need for long-term follow-up and rehabilitation programs for every ICU survivor after discharge. COVID-19 survivors treated with VV-ECMO had outcomes comparable to those reported in non-COVID patients.
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Affiliation(s)
- Alberto Lucchini
- Direction of health and social professions - General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Marta Villa
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Marco Giani
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Mara Andreossi
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Valentino Alessandra
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Veronica Vigo
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Stefano Gatti
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Daniela Ferlicca
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Maddalena Teggia Droghi
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Emanuele Rezoagli
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Giuseppe Foti
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Matteo Pozzi
- University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy; Cardiosurgical ICU Fondazione IRCCS San Gerardo dei Tintori - Monza.
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Ghanbar MI, Danoff SK. Review of Pulmonary Manifestations in Antisynthetase Syndrome. Semin Respir Crit Care Med 2024; 45:365-385. [PMID: 38710221 DOI: 10.1055/s-0044-1785536] [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: 05/08/2024]
Abstract
Antisynthetase syndrome (ASyS) is now a widely recognized entity within the spectrum of idiopathic inflammatory myopathies. Initially described in patients with a triad of myositis, arthritis, and interstitial lung disease (ILD), its presentation can be diverse. Additional common symptoms experienced by patients with ASyS include Raynaud's phenomenon, mechanic's hand, and fever. Although there is a significant overlap with polymyositis and dermatomyositis, the key distinction lies in the presence of antisynthetase antibodies (ASAs). Up to 10 ASAs have been identified to correlate with a presentation of ASyS, each having manifestations that may slightly differ from others. Despite the proposal of three classification criteria to aid diagnosis, the heterogeneous nature of patient presentations poses challenges. ILD confers a significant burden in patients with ASyS, sometimes manifesting in isolation. Notably, ILD is also often the initial presentation of ASyS, requiring pulmonologists to remain vigilant for an accurate diagnosis. This article will comprehensively review the various aspects of ASyS, including disease presentation, diagnosis, management, and clinical course, with a primary focus on its pulmonary manifestations.
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Affiliation(s)
- Mohammad I Ghanbar
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sonye K Danoff
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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Bluth T, Güldner A, Spieth PM. [Ventilation concepts under extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS)]. DIE ANAESTHESIOLOGIE 2024; 73:352-362. [PMID: 38625538 DOI: 10.1007/s00101-024-01407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.
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Affiliation(s)
- Thomas Bluth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Andreas Güldner
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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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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Le Pape S, Joly F, Arrivé F, Frat JP, Rodriguez M, Joos M, Marchasson L, Wairy M, Thille AW, Coudroy R. Factors associated with decreased compliance after on-site extracorporeal membrane oxygenation cannulation for acute respiratory distress syndrome: A retrospective, observational cohort study. JOURNAL OF INTENSIVE MEDICINE 2024; 4:194-201. [PMID: 38681786 PMCID: PMC11043634 DOI: 10.1016/j.jointm.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) is systematically associated with decreased respiratory system compliance (CRS). It remains unclear whether transportation to the referral ECMO center, changes in ventilatory mode or settings to achieve ultra-protective ventilation, or the natural evolution of ARDS drives this change in respiratory mechanics. Herein, we assessed the precise moment when CRS decreases after ECMO cannulation and identified factors associated with decreased CRS. Methods To rule out the effect of transportation and the different modes of ventilation on CRS, we conducted a retrospective, single-center, observational cohort study from January 2013 to May 2020, on 22 patients with severe ARDS requiring on-site ECMO and ventilated in pressure-controlled mode to achieve ultra-protective ventilation. CRS was assessed at different time points ranging from 12 h before ECMO cannulation to 72 h after ECMO cannulation. The primary outcome was the relative change in CRS between 3 h before and 3 h after ECMO cannulation. The secondary outcomes included variables associated with the relative changes in CRS within the first 3 h after ECMO cannulation and the relative changes in CRS at each time point. Results CRS decreased within the first 3 h after ECMO cannulation (-28.3%, 95% confidence interval [CI]: -38.8 to -17.9, P<0.001), while the decrease was mild before and after these first 3 h after ECMO cannulation. To achieve ultra-protective ventilation, respiratory rate decreased in the mean by -13 breaths/min (95% CI: -15 to -11) and driving pressure by -8.3 cmH2O (95% CI: -11.2 to -5.3), resulting in decreased tidal volume by -3.3 mL/kg of predicted body weight (95% CI: -3.9 to -2.6) as compared to before ECMO cannulation (P <0.001 for all). Plateau pressure reduction, driving pressure reduction, and tidal volume reduction were significantly associated with decreased CRS after ECMO cannulation, whereas neither respiratory rate, positive end-expiratory pressure, inspired fraction of oxygen, fluid balance, nor mean airway pressure was associated with decreased CRS. Conclusions Decreased driving pressure resulting in lower tidal volume to achieve ultra-protective ventilation after ECMO cannulation was associated with a marked decrease in CRS in ARDS patients with on-site ECMO cannulation.
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Affiliation(s)
- Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Florent Joly
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Maeva Rodriguez
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maïa Joos
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Mathilde Wairy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W. Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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Rilinger J, Book R, Kaier K, Giani M, Fumagalli B, Jäckel M, Bemtgen X, Zotzmann V, Biever PM, Foti G, Westermann D, Lepper PM, Supady A, Staudacher DL, Wengenmayer T. A Mortality Prediction Score for Patients With Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): The PREDICT VV-ECMO Score. ASAIO J 2024; 70:293-298. [PMID: 37934747 PMCID: PMC10977052 DOI: 10.1097/mat.0000000000002088] [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: 11/09/2023] Open
Abstract
Mortality prediction for patients with the severe acute respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO) is challenging. Clinical variables at baseline and on day 3 after initiation of ECMO support of all patients treated from October 2010 through April 2020 were analyzed. Multivariate logistic regression analysis was used to identify score variables. Internal and external (Monza, Italy) validation was used to evaluate the predictive value of the model. Overall, 272 patients could be included for data analysis and creation of the PREDICT VV-ECMO score. The score comprises five parameters (age, lung fibrosis, immunosuppression, cumulative fluid balance, and ECMO sweep gas flow on day 3). Higher score values are associated with a higher probability of hospital death. The score showed favorable results in derivation and external validation cohorts (area under the receiver operating curve, AUC derivation cohort 0.76 [95% confidence interval, CI, 0.71-0.82] and AUC validation cohort 0.74 [95% CI, 0.67-0.82]). Four risk classes were defined: I ≤ 30, II 31-60, III 61-90, and IV ≥ 91 with a predicted mortality of 28.2%, 56.2%, 84.8%, and 96.1%, respectively. The PREDICT VV-ECMO score suggests favorable performance in predicting hospital mortality under ongoing ECMO support providing a sound basis for further evaluation in larger cohorts.
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Affiliation(s)
- Jonathan Rilinger
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rebecca Book
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Giani
- Department School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Benedetta Fumagalli
- Department School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Markus Jäckel
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M. Biever
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Giuseppe Foti
- Department School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Dirk Westermann
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V – Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Alexander Supady
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Dawid L. Staudacher
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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10
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Kim TW, Kim WY, Park S, Lee SH, Park O, Kim T, Yeo HJ, Jang JH, Cho WH, Huh JW, Lee SM, Chung CR, Lee J, Kim JS, Lim SY, Baek AR, Yoo JW, Kim HC, Choi EY, Park C, Kim TO, Moon DS, Lee SI, Moon JY, Kwon SJ, Seong GM, Jung WJ, Baek MS. Risk Factors for the Mortality of Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation in a Non-Centralized Setting: A Nationwide Study. J Korean Med Sci 2024; 39:e75. [PMID: 38442718 PMCID: PMC10911941 DOI: 10.3346/jkms.2024.39.e75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/03/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Limited data are available on the mortality rates of patients receiving extracorporeal membrane oxygenation (ECMO) support for coronavirus disease 2019 (COVID-19). We aimed to analyze the relationship between COVID-19 and clinical outcomes for patients receiving ECMO. METHODS We retrospectively investigated patients with COVID-19 pneumonia requiring ECMO in 19 hospitals across Korea from January 1, 2020 to August 31, 2021. The primary outcome was the 90-day mortality after ECMO initiation. We performed multivariate analysis using a logistic regression model to estimate the odds ratio (OR) of 90-day mortality. Survival differences were analyzed using the Kaplan-Meier (KM) method. RESULTS Of 127 patients with COVID-19 pneumonia who received ECMO, 70 patients (55.1%) died within 90 days of ECMO initiation. The median age was 64 years, and 63% of patients were male. The incidence of ECMO was increased with age but was decreased after 70 years of age. However, the survival rate was decreased linearly with age. In multivariate analysis, age (OR, 1.048; 95% confidence interval [CI], 1.010-1.089; P = 0.014) and receipt of continuous renal replacement therapy (CRRT) (OR, 3.069; 95% CI, 1.312-7.180; P = 0.010) were significantly associated with an increased risk of 90-day mortality. KM curves showed significant differences in survival between groups according to age (65 years) (log-rank P = 0.021) and receipt of CRRT (log-rank P = 0.004). CONCLUSION Older age and receipt of CRRT were associated with higher mortality rates among patients with COVID-19 who received ECMO.
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Affiliation(s)
- Tae Wan Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Won-Young Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Su Hwan Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Onyu Park
- BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Taehwa Kim
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Transplant Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hye Ju Yeo
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Transplant Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jin Ho Jang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Transplant Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Woo Hyun Cho
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Transplant Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jongmin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Soo Kim
- Division of Critical Care Medicine, Department of Hospital Medicine, Inha Collage of Medicine, Incheon, Korea
| | - Sung Yoon Lim
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ae-Rin Baek
- Division of Allergy and Pulmonary Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jung-Wan Yoo
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Eun Young Choi
- Division of Pulmonology and Allergy, Department of Internal Medicine, College of Medicine, Yeungnam University and Regional Center for Respiratory Diseases, Yeungnam University Medical Center, Daegu, Korea
| | - Chul Park
- Division of Pulmonology and Critical Care Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Tae-Ok Kim
- Division of Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Do Sik Moon
- Department of Pulmonology and Critical Care Medicine, Chosun University Hospital, Gwangju, Korea
| | - Song-I Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Young Moon
- Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Sun Jung Kwon
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - Gil Myeong Seong
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Won Jai Jung
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Moon Seong Baek
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea.
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11
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Ferreira-da-Silva R, Maranhão P, Dias CC, Alves JM, Pires L, Morato M, Polónia JJ, Ribeiro-Vaz I. Assessing medication use patterns by clinical outcomes severity among inpatients with COVID-19: A retrospective drug utilization study. Biomed Pharmacother 2024; 172:116242. [PMID: 38340395 DOI: 10.1016/j.biopha.2024.116242] [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: 12/10/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
PURPOSE This study assessed medication patterns for inpatients at a central hospital in Portugal and explored their relationships with clinical outcomes in COVID-19 cases. METHODS A retrospective study analyzed inpatient medication data, coded using the Anatomical Therapeutic Chemical classification system, from electronic patient records. It investigated the association between medications and clinical severity outcomes such as ICU admissions, respiratory/circulatory support needs, and hospital discharge status, including mortality (identified by ICD-10-CM/PCS codes). Multivariate analyses incorporating demographic data and comorbidities were used to adjust for potential confounders and understand the impact of medication patterns on disease progression and outcomes. RESULTS The analysis of 2688 hospitalized COVID-19 patients (55.3% male, average age 62.8 years) revealed a significant correlation between medication types and intensity and disease severity. Cases requiring ICU admission or ECMO support often involved blood and blood-forming organ drugs. Increased use of nervous system and genitourinary hormones was observed in nonsurvivors. Corticosteroids, like dexamethasone, were common in critically ill patients, while tocilizumab was used in ECMO cases. Medications for the alimentary tract, metabolism, and cardiovascular system, although widely prescribed, were linked to more severe cases. Invasive mechanical ventilation correlated with higher usage of systemic anti-infectives and musculoskeletal medications. Trends in co-prescribing blood-forming drugs with those for acid-related disorders, analgesics, and antibacterials were associated with intensive interventions and worse outcomes. CONCLUSIONS The study highlights complex medication regimens in managing severe COVID-19, underscoring specific drug patterns associated with critical health outcomes. Further research is needed to explore these patterns.
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Affiliation(s)
- Renato Ferreira-da-Silva
- Porto Pharmacovigilance Centre, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal.
| | - Priscila Maranhão
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Cláudia Camila Dias
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Knowledge Management Unit, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - João Miguel Alves
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Lígia Pires
- Pulmonology Service, Algarve University Hospital Center, Faro, Portugal; Intensive Care Unit, Algarve Private Hospital, Faro, Portugal
| | - Manuela Morato
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy of the University of Porto, Porto, Portugal; LAQV@REQUIMTE, Faculty of Pharmacy of the University of Porto, Porto, Portugal
| | - Jorge Junqueira Polónia
- Porto Pharmacovigilance Centre, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Medicine, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Ribeiro-Vaz
- Porto Pharmacovigilance Centre, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
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12
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Yamashita T, Uchiyama A, Enokidani Y, Yoshida T, Fujino Y. Combined Use of Alkaline Agents With Low-Flow Extracorporeal Carbon Dioxide Removal in Carbon Dioxide Inhalation Models Preserving Inspiratory Efforts. J Acute Med 2024; 14:28-38. [PMID: 38487759 PMCID: PMC10933589 DOI: 10.6705/j.jacme.202403_14(1).0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/23/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2024]
Abstract
Background Low-flow extracorporeal CO 2 removal (ECCO 2 R), managed using a renal replacement platform, is useful in achieving lung-protective ventilation with low tidal volume. However, its capacity for CO 2 elimination is limited. Whether this system is valuable in reducing strong inspiratory efforts in respiratory failure is unclear. The combined use of alkaline agents with low-flow ECCO 2 R might be useful in hypercapnic subjects preserving inspiratory efforts. Methods This study examined the effects of low-flow ECCO 2 R on respiratory status and investigated the effects of NaHCO 3 , trometamol, and saline on respiratory status during low-flow ECCO 2 R in CO 2 inhalation models. Results Although low-flow ECCO 2 R did not significantly change the respiratory rate (92.2% ± 24.3% [mean ± standard deviation] of that before ECCO 2 R), it reduced minute ventilation (MV) (78.9% ± 13.5% of that before ECCO 2 R). The addition of NaHCO 3 improved acidemia but did not change MV compared with that of the saline group (0.451 ± 0.026 L/min/kg body weight [BW] vs. 0.556 ± 0.138 L/min/kg BW, respectively). The addition of trometamol improved acidemia and reduced MV compared with that of the saline group (0.381 ± 0.050 L/min/kg BW vs. 0.556 ± 0.138 L/min/kg BW, respectively). The total amounts of CO 2 removed during ECCO 2 R in the NaHCO 3 group were lower than those in the saline and trometamol groups. Conclusion The low-flow ECCO 2 R reduced MV in subjects preserving spontaneous breathing efforts with CO 2 overload. The addition of NaHCO 3 improved acidemia but did not change MV, whereas the addition of trometamol improved acidemia and reduced MV.
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Affiliation(s)
- Tomonori Yamashita
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Akinori Uchiyama
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Yusuke Enokidani
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Takeshi Yoshida
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Yuji Fujino
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
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13
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Thiara S, Stukas S, Hoiland R, Wellington C, Tymko M, Isac G, Finlayson G, Kanji H, Romano K, Hirsch-Reinshagen V, Sekhon M, Griesdale D. Characterizing the Relationship Between Arterial Carbon Dioxide Trajectory and Serial Brain Biomarkers with Central Nervous System Injury During Veno-Venous Extracorporeal Membrane Oxygenation: A Prospective Cohort Study. Neurocrit Care 2024:10.1007/s12028-023-01923-x. [PMID: 38302643 DOI: 10.1007/s12028-023-01923-x] [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: 05/22/2023] [Accepted: 12/13/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Central nervous system (CNS) injury following initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) is common. An acute decrease in partial pressure of arterial carbon dioxide (PaCO2) following VV-ECMO initiation has been suggested as an etiological factor, but the challenges of diagnosing CNS injuries has made discerning a relationship between PaCO2 and CNS injury difficult. METHODS We conducted a prospective cohort study of adult patients undergoing VV-ECMO for acute respiratory failure. Arterial blood gas measurements were obtained prior to initiation of VV-ECMO, and at every 2-4 h for the first 24 h. Neuroimaging was conducted within the first 7-14 days in patients who were suspected of having neurological injury or unable to be examined because of sedation. We collected blood biospecimens to measure brain biomarkers [neurofilament light (NF-L); glial fibrillary acidic protein (GFAP); and phosphorylated-tau 181] in the first 7 days following initiation of VV-ECMO. We assessed the relationship between both PaCO2 over the first 24 h and brain biomarkers with CNS injury using mixed methods linear regression. Finally, we explored the effects of absolute change of PaCO2 on serum levels of neurological biomarkers by separate mixed methods linear regression for each biomarker using three PaCO2 exposures hypothesized to result in CNS injury. RESULTS In our cohort, 12 of 59 (20%) patients had overt CNS injury identified on head computed tomography. The PaCO2 decrease with VV-ECMO initiation was steeper in patients who developed a CNS injury (- 0.32%, 95% confidence interval - 0.25 to - 0.39) compared with those without (- 0.18%, 95% confidence interval - 0.14 to - 0.21, P interaction < 0.001). The mean concentration of NF-L increased over time and was higher in those with a CNS injury (464 [739]) compared with those without (127 [257]; P = 0.001). GFAP was higher in those with a CNS injury (4278 [11,653] pg/ml) compared with those without (116 [108] pg/ml; P < 0.001). The mean NF-L, GFAP, and tau over time in patients stratified by the three thresholds of absolute change of PaCO2 showed no differences and had no significant interaction for time. CONCLUSIONS Although rapid decreases in PaCO2 following initiation of VV-ECMO were slightly greater in patients who had CNS injuries versus those without, data overlap and absence of relationships between PaCO2 and brain biomarkers suggests other pathophysiologic variables are likely at play.
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Affiliation(s)
- Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Sophie Stukas
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl Wellington
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mike Tymko
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - George Isac
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gordon Finlayson
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Hussein Kanji
- Department of Emergency Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Kali Romano
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
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14
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Li W, Chen Y, Li D, Meng X, Liu Z, Liu Y, Fan H. Hemoadsorption in acute respiratory distress syndrome patients requiring venovenous extracorporeal membrane oxygenation: a systematic review. Respir Res 2024; 25:27. [PMID: 38217010 PMCID: PMC10785465 DOI: 10.1186/s12931-024-02675-8] [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: 07/23/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Venovenous extracorporeal membrane oxygenation (VV ECMO) has been widely used for severe acute respiratory distress syndrome (ARDS) in recent years. However, the role of hemoadsorption in ARDS patients requiring VV ECMO is unclear. METHODS Therefore, we conducted a systematic review to describe the effect of hemoadsorption on outcomes of ARDS patients requiring VV ECMO and elucidate the risk factors for adverse outcomes. We conducted and reported a systematic literature review based on the principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The systematic review searched Embase, CINHAL, and Pubmed databases for studies on ARDS patients receiving hemoadsorption and VV ECMO. The demographic data, clinical data and biological data of the patients were collected. RESULTS We ultimately included a total of 8 articles including 189 patients. We characterized the population both clinically and biologically. Our review showed most studies described reductions in inflammatory markers and fluid resuscitation drug dosage in ARDS patients with Coronavirus disease 2019 (COVID-19) or sepsis after hemoadsorption. CONCLUSION Because most of the studies have the characteristics of high heterogeneity, we could only draw very cautious conclusions that hemoadsorption therapy may enhance hemodynamic stability in ARDS patients with COVID-19 or sepsis receiving VV ECMO support. However, our results do not allow us to draw conclusions that hemoadsorption could reduce inflammation and mortality. Prospective randomized controlled studies with a larger sample size are needed in the future to verify the role of hemoadsorption in ARDS patients requiring VV ECMO.
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Affiliation(s)
- Wenli Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.
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15
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Zhang R, Zhai K, Huang J, Wei S, Yang J, Zhang Y, Wu X, Li Y, Gao B. Sevoflurane alleviates lung injury and inflammatory response compared with propofol in a rat model of VV ECMO. Perfusion 2024; 39:142-150. [PMID: 36206156 DOI: 10.1177/02676591221131217] [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: 11/15/2022]
Abstract
INTRODUCTION Although venovenous extracorporeal membrane oxygenation (VV ECMO) is a reasonable salvage treatment for acute respiratory distress syndrome (ARDS), it requires sedating the patient. Sevoflurane and propofol have pulmonary protective and immunomodulatory properties. This study aimed to compare the effectiveness of sevoflurane and propofol on rats with induced ARDS undergoing VV ECMO. METHODS Fifteen sprague-dawley (SD) rats were randomly divided into three groups: Con group, sevoflurane (Sevo) group and propofol (Pro) group. Arterial blood gas tests were performed at time pointsT0 (baseline), T1 (the time to ARDS), and T2 (weaning from ECMO). Oxygenation index (PaO2/FiO2) was calculated, and lung edema assessed by determining the lung wet:dry ratio. The protein concentration in bronchial alveolar lavage fluid (BALF) was determined by using bicinchoninic acid assay. Haematoxylin and eosin staining was used to evaluate the lung pathological scores in each group. IL-1β and TNF-α were also measured in the BALF, serum and lung. RESULTS Oxygenation index showed improvement in the Sevo group versus Pro group. The wet:dry ratio was reduced in the Sevo group compared with propofol-treated rats. Lung pathological scores were substantially lower in the Sevo group versus the Pro group. Protein concentrations in the BALF and levels of IL-1β and TNF-α in the Sevo group were substantially lower versus Pro group. CONCLUSION This study demonstrates that compared with propofol, sevoflurane was more efficacious in improving oxygenation and decreasing inflammatory response in rat models with ARDS subject to VV ECMO treatment.
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Affiliation(s)
- Rongzhi Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Kerong Zhai
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Jian Huang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Shilin Wei
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Yanchun Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Xiangyang Wu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
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Gerhardinger F, Fisser C, Malfertheiner MV, Philipp A, Foltan M, Zeman F, Stadlbauer A, Wiest C, Lunz D, Müller T, Lubnow M. Prevalence and Risk Factors for Weaning Failure From Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Insufficiency. Crit Care Med 2024; 52:54-67. [PMID: 37665263 DOI: 10.1097/ccm.0000000000006041] [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: 09/05/2023]
Abstract
OBJECTIVE Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency. DESIGN Single-center retrospective observational study. SETTING Sixteen beds medical ICU at the University Hospital Regensburg. PATIENTS Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients meeting our ECMO weaning criteria (Sp o2 ≥ 90% with F io2 ≤ 0.4 or Pa o2 /F io2 > 150 mm Hg, pH = 7.35-7.45, positive end-expiratory pressure ≤ 10 cm H 2 O, driving pressure < 15 cm H 2 O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90-160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co2 : odds ratio [OR] 1.05; 95% CI, 1.001-1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04-1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o2 and Pa o2 /F io2 during EWTs was higher in failed than successful trials. CONCLUSIONS Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure.
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Affiliation(s)
- Felix Gerhardinger
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Clemens Wiest
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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17
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Lichter Y, Gal Oz A, Carmi U, Adi N, Nini A, Angel Y, Nevo A, Aviram D, Moshkovits I, Goder N, Stavi D. Kinetics of C-reactive protein during extracorporeal membrane oxygenation. Int J Artif Organs 2024; 47:41-48. [PMID: 38031425 PMCID: PMC10787388 DOI: 10.1177/03913988231213511] [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: 12/01/2023]
Abstract
BACKGROUND The exposure of blood to the artificial circuit during extracorporeal membrane oxygenation (ECMO) can induce an inflammatory response. C-reactive protein (CRP) is a commonly used biomarker of systemic inflammation. METHODS In this retrospective observational study, we analyzed results of daily plasma CRP measurements in 110 critically ill patients, treated with ECMO. We compared CRP levels during the first 5 days of ECMO operation, between different groups of patients according to ECMO configurations, Coronavirus disease 2019 (COVID-19) status, and mechanical ventilation parameters. RESULTS There was a statistically significant decrease in CRP levels during the first 5 days of veno-venous (VV) ECMO (173 ± 111 mg/L, 154 ± 107 mg/L, 127 ± 97 mg/L, 114 ± 100 mg/L and 118 ± 90 mg/L for days 1-5 respectively, p < 0.001). Simultaneously, there was a significant reduction in ventilatory parameters, as represented by the mechanical power (MP) calculation, from 24.02 ± 14.53 J/min to 6.18 ± 4.22 J/min within 3 h of VV ECMO initiation (p < 0.001). There was non-significant trend of increase in CRP level during the first 5 days of veno arterial (VA) ECMO (123 ± 80 mg/L, 179 ± 91 mg/L, 203 ± 90 mg/L, 179 ± 95 mg/L and 198 ± 93 for days 1-5 respectively, p = 0.126) and no significant change in calculated MP (from 14.28 ± 8.56 J/min to 10.81 ± 8.09 J/min within 3 h if ECMO initiation, p = 0.071). CONCLUSIONS We observed a significant decrease in CRP levels during the first 5 days of VV ECMO support, and suggest that the concomitant reduction in ventilatory MP may have mitigated the degree of alveolar stress and strain that could have contributed to a decrease in the systemic inflammatory process.
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Affiliation(s)
- Yael Lichter
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Gal Oz
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Carmi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Adi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaph Nini
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Angel
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrey Nevo
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Aviram
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itay Moshkovits
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Goder
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dekel Stavi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Shi X, Shi Y, Fan L, Yang J, Chen H, Ni K, Yang J. Prognostic value of oxygen saturation index trajectory phenotypes on ICU mortality in mechanically ventilated patients: a multi-database retrospective cohort study. J Intensive Care 2023; 11:59. [PMID: 38031107 PMCID: PMC10685672 DOI: 10.1186/s40560-023-00707-x] [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: 07/27/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Heterogeneity among critically ill patients undergoing invasive mechanical ventilation (IMV) treatment could result in high mortality rates. Currently, there are no well-established indicators to help identify patients with a poor prognosis in advance, which limits physicians' ability to provide personalized treatment. This study aimed to investigate the association of oxygen saturation index (OSI) trajectory phenotypes with intensive care unit (ICU) mortality and ventilation-free days (VFDs) from a dynamic and longitudinal perspective. METHODS A group-based trajectory model was used to identify the OSI-trajectory phenotypes. Associations between the OSI-trajectory phenotypes and ICU mortality were analyzed using doubly robust analyses. Then, a predictive model was constructed to distinguish patients with poor prognosis phenotypes. RESULTS Four OSI-trajectory phenotypes were identified in 3378 patients: low-level stable, ascending, descending, and high-level stable. Patients with the high-level stable phenotype had the highest mortality and fewest VFDs. The doubly robust estimation, after adjusting for unbalanced covariates in a model using the XGBoost method for generating propensity scores, revealed that both high-level stable and ascending phenotypes were associated with higher mortality rates (odds ratio [OR]: 1.422, 95% confidence interval [CI] 1.246-1.623; OR: 1.097, 95% CI 1.027-1.172, respectively), while the descending phenotype showed similar ICU mortality rates to the low-level stable phenotype (odds ratio [OR] 0.986, 95% confidence interval [CI] 0.940-1.035). The predictive model could help identify patients with ascending or high-level stable phenotypes at an early stage (area under the curve [AUC] in the training dataset: 0.851 [0.827-0.875]; AUC in the validation dataset: 0.743 [0.709-0.777]). CONCLUSIONS Dynamic OSI-trajectory phenotypes were closely related to the mortality of ICU patients requiring IMV treatment and might be a useful prognostic indicator in critically ill patients.
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Affiliation(s)
- Xiawei Shi
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Yangyang Shi
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Liming Fan
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Hao Chen
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kaiwen Ni
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Junchao Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China.
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19
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Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [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: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
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20
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Xu H, Sheng S, Luo W, Xu X, Zhang Z. Acute respiratory distress syndrome heterogeneity and the septic ARDS subgroup. Front Immunol 2023; 14:1277161. [PMID: 38035100 PMCID: PMC10682474 DOI: 10.3389/fimmu.2023.1277161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is an acute diffuse inflammatory lung injury characterized by the damage of alveolar epithelial cells and pulmonary capillary endothelial cells. It is mainly manifested by non-cardiogenic pulmonary edema, resulting from intrapulmonary and extrapulmonary risk factors. ARDS is often accompanied by immune system disturbance, both locally in the lungs and systemically. As a common heterogeneous disease in critical care medicine, researchers are often faced with the failure of clinical trials. Latent class analysis had been used to compensate for poor outcomes and found that targeted treatment after subgrouping contribute to ARDS therapy. The subphenotype of ARDS caused by sepsis has garnered attention due to its refractory nature and detrimental consequences. Sepsis stands as the most predominant extrapulmonary cause of ARDS, accounting for approximately 32% of ARDS cases. Studies indicate that sepsis-induced ARDS tends to be more severe than ARDS caused by other factors, leading to poorer prognosis and higher mortality rate. This comprehensive review delves into the immunological mechanisms of sepsis-ARDS, the heterogeneity of ARDS and existing research on targeted treatments, aiming to providing mechanism understanding and exploring ideas for accurate treatment of ARDS or sepsis-ARDS.
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Affiliation(s)
- Huikang Xu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shiying Sheng
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Weiwei Luo
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaofang Xu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of the Diagnosis and Treatment for Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
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21
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [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: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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22
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Fukuda M, Sakai H, Koh K, Sakuraba S, Ando N, Hayashida M, Kawagoe I. Unusual severe hypoxemia due to unilateral pulmonary edema after conventional cardiopulmonary bypass salvaged by veno-venous extracorporeal membrane oxygenation: a case report. JA Clin Rep 2023; 9:65. [PMID: 37803183 PMCID: PMC10558410 DOI: 10.1186/s40981-023-00656-2] [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: 09/04/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND We report a case in which veno-venous extracorporeal membrane oxygenation (V-V ECMO) saved the life of a patient who developed severe hypoxemia due to unusual unilateral pulmonary edema (UPE) after cardiopulmonary bypass (CPB). CASE PRESENTATION A 69-year-old man underwent aortic valve replacement and coronary artery bypass grafting. Following uneventful weaning off CPB, he developed severe hypoxemia. The ratio of arterial oxygen tension to inspired oxygen fraction (PaO2/FiO2) decreased from 301 mmHg 5 min after CPB to 42 mmHg 90 min after CPB. A chest X-ray revealed right-sided UPE. Immediately established V-V ECMO increased PaO2/FiO2 to 170 mmHg. Re-expansion pulmonary edema (REPE) was likely, as the right lung remained collapsed during CPB following the accidental opening of the right chest cavity during graft harvesting. CONCLUSIONS V-V ECMO was effective in improving oxygenation and saving the life of a patient who had fallen into unilateral REPE unusually developing after conventional CPB.
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Affiliation(s)
- Masataka Fukuda
- Department of Anesthesiology and Pain Medicine, Juntendo University Hospital, Tokyo, 113-8431, Japan
| | - Hiroaki Sakai
- Department of Anesthesia, Fujieda Municipal General Hospital, Shizuoka, Japan
| | - Keito Koh
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Sonoko Sakuraba
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Nozomi Ando
- Department of Anesthesiology and Pain Medicine, Juntendo University Hospital, Tokyo, 113-8431, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University Hospital, Tokyo, 113-8431, Japan
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University Hospital, Tokyo, 113-8431, Japan.
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23
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Ghonim MA, Boyd DF, Flerlage T, Thomas PG. Pulmonary inflammation and fibroblast immunoregulation: from bench to bedside. J Clin Invest 2023; 133:e170499. [PMID: 37655660 PMCID: PMC10471178 DOI: 10.1172/jci170499] [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] [Indexed: 09/02/2023] Open
Abstract
In recent years, there has been an explosion of interest in how fibroblasts initiate, sustain, and resolve inflammation across disease states. Fibroblasts contain heterogeneous subsets with diverse functionality. The phenotypes of these populations vary depending on their spatial distribution within the tissue and the immunopathologic cues contributing to disease progression. In addition to their roles in structurally supporting organs and remodeling tissue, fibroblasts mediate critical interactions with diverse immune cells. These interactions have important implications for defining mechanisms of disease and identifying potential therapeutic targets. Fibroblasts in the respiratory tract, in particular, determine the severity and outcome of numerous acute and chronic lung diseases, including asthma, chronic obstructive pulmonary disease, acute respiratory distress syndrome, and idiopathic pulmonary fibrosis. Here, we review recent studies defining the spatiotemporal identity of the lung-derived fibroblasts and the mechanisms by which these subsets regulate immune responses to insult exposures and highlight past, current, and future therapeutic targets with relevance to fibroblast biology in the context of acute and chronic human respiratory diseases. This perspective highlights the importance of tissue context in defining fibroblast-immune crosstalk and paves the way for identifying therapeutic approaches to benefit patients with acute and chronic pulmonary disorders.
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Affiliation(s)
- Mohamed A. Ghonim
- Department of Immunology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Microbiology and Immunology, Faculty of Pharmacy, Al Azhar University, Cairo, Egypt
| | - David F. Boyd
- Molecular, Cell and Developmental Biology, University of California, Santa Cruz, Santa Cruz, California, USA
| | - Tim Flerlage
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Paul G. Thomas
- Department of Immunology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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24
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Lucchini A, Elli S, Piovera D, Grossulè M, Giannini L, Cannizzo L, Crosignani A, Rona R, Foti G, Giani M. Management of vascular access for extracorporeal life support: A cohort study. J Vasc Access 2023; 24:1167-1173. [PMID: 34763544 DOI: 10.1177/11297298211056755] [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] [Indexed: 11/17/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is required for patients with refractory cardiac or respiratory failure. Inadequate securement of ECMO cannulae may lead to adverse events, ranging from line kinking to catastrophic accidents, such as air entrainment into the circuit or massive bleeding. Furthermore, the micro-motion of the cannulae at the entry site might increase the risk of local infections. Since 2015, we implemented a written protocol for management of ECMO cannulae and tubing, which specifically includes the securement of each cannula with three sutureless devices. The aim of the present study was to retrospectively assess cannulae micro-motion and the rate of bleeding events at the insertion site. Secondarily we aimed to evaluate the impact of prone positioning maneuvers during ECMO on these events. We performed a single-centre retrospective analysis of prospectively collected data on nursing care of ECMO cannulae. We included adult patients treated with veno-venous (V-V) or veno-arterial (V-A) ECMO between 2015 and 2018 in our general intensive care unit. The distance between the insertion site and the end of the wire-wound part of the cannula was recorded daily. Variations of this distance (defined as "cannula micro-motion") were recorded. Forty-five ECMO consecutive adult patients (40 V-V and 5 V-A) were included. No accidental cannula dislodgement was recorded. Median daily "cannula micro-motion" was 0.0 (-0.5 to 0.2) cm, without any significant difference between ECMO configuration, cannula type, and insertion site. Twelve patients (26%) presented at least one bleeding episode at cannula insertion site, none of which required surgical intervention. In the subgroup of patients who underwent prone positioning, no difference in cannulae micro-motion was recorded. An ECMO nursing protocol for cannulae management providing sutureless devices for cannula and tubing securement allows safe line stabilization, with the potential to reduce complications related to ECMO vascular access.
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Affiliation(s)
- Alberto Lucchini
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Stefano Elli
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Daniele Piovera
- General Intensive Care and ECMO Unit, IRCCS San Matteo, Pavia, Italy
| | | | - Luciano Giannini
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Luigi Cannizzo
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Andrea Crosignani
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Roberto Rona
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Guseppe Foti
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Marco Giani
- General Intensive Care Unit, Emergency Department, ASST Monza San Gerardo Hospital, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
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Behouche A, Gaide-Chevronnay L, Piot J, Durost M, Adolle A, Le Guen Y, Vilotitch A, Bosson JL, Sebestyen A, Durand M, Albaladejo P. Early extubation in extracorporeal life support patients: A propensity score-matched study. Artif Organs 2023; 47:1342-1350. [PMID: 37005770 DOI: 10.1111/aor.14532] [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: 12/26/2022] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Extubation strategy in extracorporeal life support patients remains unclear, and literature only reports studies with significant biases. OBJECTIVES To explore the prognostic impact of an early ventilator-weaning strategy in assisted patients after controlling for confounding factors. METHODS A 10-year retrospective study included 241 patients receiving extracorporeal life support for at least 48 h, corresponding to a total of 977 days spent on assistance. The a priori probability of extubation for each day of assistance was calculated according to daily biological examinations, drug doses, clinical observations, and admission data to pair each day containing an extubation with one on which the patient was not extubated. The primary outcome was survival at day 28. The secondary outcomes were survival at day 7, respiratory infections, and safety criteria. RESULTS Two similar cohorts of 61 patients were generated. Survival at day 28 was better in patients extubated under assistance in univariate and multivariate (HR = 0.37 [0.2-0.68], p-value = 0.002) analyses. Patients who underwent failed early extubation did not have a different prognosis from those without early extubation. Successful early extubation was associated with a better outcome than a failed or no attempt at early extubation. Survival at day 7 and the rate of respiratory infections were better in early-extubated patients. Safety data did not differ between the two groups. CONCLUSIONS Early extubation during assistance was associated with a superior outcome in our propensity-matched cohort study. The safety data were reassuring. However, due to the lack of prospective randomized studies, the causality remains uncertain.
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Affiliation(s)
- Alexandre Behouche
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Lucie Gaide-Chevronnay
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Juliette Piot
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Maxime Durost
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Anais Adolle
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Yann Le Guen
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Antoine Vilotitch
- Data Engineering Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Luc Bosson
- Grenoble Alpes University Hospital, Themas, Timc-Imag Umr-5525, Grenoble, France
| | - Alexandre Sebestyen
- Department of Cardiac Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Michel Durand
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Pierre Albaladejo
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
- Grenoble Alpes University Hospital, Themas, Timc-Imag Umr-5525, Grenoble, France
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Girgis RE, Hadley RJ, Murphy ET. Pulmonary, circulatory and renal considerations in the early postoperative management of the lung transplant recipient. Glob Cardiol Sci Pract 2023; 2023:e202318. [PMID: 37575284 PMCID: PMC10422876 DOI: 10.21542/gcsp.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/15/2023] [Indexed: 08/15/2023] Open
Abstract
Lung transplantation volumes and survival rates continue to increase worldwide. Primary graft dysfunction (PGD) and acute kidney injury (AKI) are common early postoperative complications that significantly affect short-term mortality and long-term outcomes. These conditions share overlapping risk factors and are driven, in part, by circulatory derangements. The prevalence of severe PGD is up to 20% and is the leading cause of early death. Patients with pulmonary hypertension are at a higher risk. Prevention and management are based on principles learned from acute lung injury of other causes. Targeting the lowest effective cardiac filling pressure will reduce alveolar edema formation in the setting of increased pulmonary capillary permeability. AKI is reported in up to one-half of lung transplant recipients and is strongly associated with one-year mortality as well as long-term chronic kidney disease. Optimization of renal perfusion is critical to reduce the incidence and severity of AKI. In this review, we highlight key early post-transplant pulmonary, circulatory, and renal perturbations and our center's management approach.
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Affiliation(s)
- Reda E. Girgis
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
| | - Ryan J. Hadley
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
| | - Edward T. Murphy
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
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Teijeiro-Paradis R, Grenier J, Urner M, Douflé G, Steel A, Cypel M, Keshavjee S, Herridge M, Goligher E, Granton J, Ferguson N, Fan E, Del Sorbo L. Outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation: a prospective observational study. Can J Anaesth 2023; 70:1226-1233. [PMID: 37280459 PMCID: PMC10243882 DOI: 10.1007/s12630-023-02501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 06/08/2023] Open
Abstract
PURPOSE Descriptive information on referral patterns and short-term outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation (ECMO) is lacking. METHODS We conducted a prospective single-centre observational cohort study of ECMO referrals to Toronto General Hospital (receiving hospital) for severe respiratory failure (COVID-19 and non-COVID-19), between 1 December 2019 and 30 November 2020. Data related to the referral, the referral decision, and reasons for refusal were collected. Reasons for refusal were grouped into three mutually exclusive categories selected a priori: "too sick now," "too sick before," and "not sick enough." In declined referrals, referring physicians were surveyed to collect patient outcome on day 7 after the referral. The primary study endpoints were referral outcome (accepted/declined) and patient outcome (alive/deceased). RESULTS A total of 193 referrals were included; 73% were declined for transfer. Referral outcome was influenced by age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95 to 0.96; P < 0.01) and involvement of other members of the ECMO team in the discussion (OR, 4.42; 95% CI, 1.28 to 15.2; P < 0.01). Patient outcomes were missing in 46 (24%) referrals (inability to locate the referring physician or the referring physician being unable to recall the outcome). Using available data (95 declined and 52 accepted referrals; n = 147), survival to day 7 was 49% for declined referrals (35% for patients deemed "too sick now," 53% for "too sick before," 100% for "not sick enough," and 50% for reason for refusal not reported) and 98% for transferred patients. Sensitivity analysis setting missing outcomes to directional extreme values retained robustness of survival probabilities. CONCLUSION Nearly half of the patients declined for ECMO consideration were alive on day 7. More information on patient trajectory and long-term outcomes in declined referrals is needed to refine selection criteria.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jasmine Grenier
- Department of Critical Care, Scarborough Health Network, Scarborough, ON, Canada
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Steel
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Margaret Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada.
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Zochios V, Yusuff H, Antonini MV, Schmidt M, Shekar K. Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset? ASAIO J 2023; 69:511-518. [PMID: 37000676 DOI: 10.1097/mat.0000000000001930] [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: 04/01/2023] Open
Affiliation(s)
- Vasileios Zochios
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Hakeem Yusuff
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition 75651, Paris Cedex 13, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, Queensland, Australia
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29
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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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30
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Zhang R, Chen H, Teng R, Li Z, Yang Y, Qiu H, Liu L. Association between the time-varying arterial carbon dioxide pressure and 28-day mortality in mechanically ventilated patients with acute respiratory distress syndrome. BMC Pulm Med 2023; 23:129. [PMID: 37076846 PMCID: PMC10113995 DOI: 10.1186/s12890-023-02431-6] [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: 11/28/2022] [Accepted: 04/13/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Recent studies have shown an association between baseline arterial carbon dioxide pressure (PaCO2) and outcomes in patients with acute respiratory distress syndrome (ARDS). However, PaCO2 probably varies throughout the disease, and few studies have assessed the effect of longitudinal PaCO2 on prognosis. We thus aimed to investigate the association between time-varying PaCO2 and 28-day mortality in mechanically ventilated ARDS patients. METHODS In this retrospective study, we included all adult (≥ 18 years) patients diagnosed with ARDS who received mechanical ventilation for at least 24 h at a tertiary teaching hospital between January 2014 and March 2021. Patients were excluded if they received extracorporeal membrane oxygenation (ECMO). Demographic data, respiratory variables, and daily PaCO2 were extracted. The primary outcome was 28-day mortality. Time-varying Cox models were used to estimate the association between longitudinal PaCO2 measurements and 28-day mortality. RESULTS A total of 709 patients were eligible for inclusion in the final cohort, with an average age of 65 years, of whom 70.7% were male, and the overall 28-day mortality was 35.5%. After adjustment for baseline confounders, including age and severity of disease, a significant increase in the hazard of death was found to be associated with both time-varying PaCO2 (HR 1.07, 95% CI 1.03-1.11, p<0.001) and the time-varying coefficient of variation for PaCO2 (HR 1.24 per 10% increase, 95% CI 1.10-1.40, p<0.001) during the first five days of invasive mechanical ventilation. The cumulative proportion of exposure to normal PaCO2 (HR 0.72 per 10% increase, 95% CI 0.58-0.89, p = 0.002) was associated with 28-day mortality. CONCLUSION PaCO2 should be closely monitored in mechanically ventilated ARDS patients. The association between PaCO2 and 28-day mortality persisted over time. Increased cumulative exposure to normal PaCO2 was associated with a decreased risk of death.
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Affiliation(s)
- Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215000, China
| | - Ran Teng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China
| | - Zuxian Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, 210009, China.
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31
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Di Nardo M, MacLaren G, Schellongowski P, Azoulay E, DeZern AE, Gutierrez C, Antonelli M, Antonini MV, Beutel G, Combes A, Diaz R, Fawzy Hassan I, Fowles JA, Jeong IS, Kochanek M, Liebregts T, Lueck C, Moody K, Moore JA, Munshi L, Paden M, Pène F, Puxty K, Schmidt M, Staudacher D, Staudinger T, Stemmler J, Stephens RS, Vande Vusse L, Wohlfarth P, Lorusso R, Amodeo A, Mahadeo KM, Brodie D. Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement. THE LANCET. RESPIRATORY MEDICINE 2023; 11:477-492. [PMID: 36924784 DOI: 10.1016/s2213-2600(22)00535-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 03/16/2023]
Abstract
Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Paediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - Peter Schellongowski
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, University of Paris, Paris, France
| | - Amy E DeZern
- Division of Hematologic Malignancies, Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Cristina Gutierrez
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Marta V Antonini
- Anaesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | | | | | - Jo-Anne Fowles
- Division of Surgery, Transplant and Anaesthetics, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center of Integrated Oncology, Aachen-Bonn-Cologne-Dusseldorf, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Tobias Liebregts
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Catherina Lueck
- Department of Hematology and Stem Cell Transplantation, West-German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karen Moody
- Division of Pediatrics, Palliative and Supportive Care Section, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica A Moore
- Section of Integrated Ethics in Cancer Care, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Matthew Paden
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Centre & Université Paris Cité, Paris, France
| | - Kathryn Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, INSERM, UMRS_1166-ICAN, Sorbonne Université, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Dawid Staudacher
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Staudinger
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Joachim Stemmler
- Department of Hematology and Oncology, University Hospital, LMU Munich, Munich, Germany
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Vande Vusse
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Philipp Wohlfarth
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Antonio Amodeo
- Cardiac Surgery Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kris M Mahadeo
- Pediatric Transplant and Cellular Therapy, Duke University, Durham, NC, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MA, USA
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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
Mechanical circulatory support (MCS) devices provide temporary or intermediate- to long-term support for acute cardiopulmonary support. In the last 20 to 30 years, tremendous growth in MCS device usage has been seen. These devices offer support for isolated respiratory failure, isolated cardiac failure, or both. Initiation of MCS devices requires the input from multidisciplinary teams using patient factors and institutional resources to guide decision making, along with a planned "exit strategy" for bridge to decision, bridge to transplant, bridge to recovery, or as destination therapy. Important considerations for MCS use include patient selection, cannulation/insertion strategies, and complications of each device.
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Affiliation(s)
- Suzanne Bennett
- Department of Anesthesiology, University of Cincinnati College of Medicine, 2139 Albert Sabin Way, Cincinnati, OH 45267-0531, USA.
| | - Lauren Sutherland
- Columbia University Irving Medical Center, 622 W 168(th) Street, New York, NY 10032, USA
| | - Promise Ariyo
- Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Frank M O'Connell
- Anesthesiology, Atlanticare Regional Medical Center, 65 W Jimmie Leeds Road, Pomona, NJ 08240, USA
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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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Martin AK, Feinman JW, Bhatt HV, Fritz AV, Subramani S, Malhotra AK, Townsley MM, Sharma A, Patel SJ, Ha B, Gui JL, Zaky A, Labe S, Teixeira MT, Morozowich ST, Weiner MM, Ramakrishna H. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2022. J Cardiothorac Vasc Anesth 2023; 37:201-213. [PMID: 36437141 DOI: 10.1053/j.jvca.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
This special article is the 15th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief Dr. Kaplan and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialties of cardiothoracic and vascular anesthesiology. The major themes selected for 2022 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights, in the specialties for 2022, begin with an update on COVID-19 therapies, with a focus on the temporal updates in a wide range of therapies, progressing from medical to the use of extracorporeal membrane oxygenation and, ultimately, with lung transplantation in this high-risk group. The second major theme is focused on medical cardiology, with the authors discussing new insights into the life cycle of coronary disease, heart failure treatments, and outcomes related to novel statin therapy. The third theme is focused on mechanical circulatory support, with discussions focusing on both right-sided and left-sided temporary support outcomes and the optimal timing of deployment. The fourth and final theme is an update on cardiac surgery, with a discussion of the diverse aspects of concomitant valvular surgery and the optimal approach to procedural treatment for coronary artery disease. The themes selected for this 15th special article are only a few of the diverse advances in the specialties during 2022. These highlights will inform the reader of key updates on a variety of topics, leading to the improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.
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Affiliation(s)
- Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL.
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Himani V Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita K Malhotra
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Saumil J Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jane L Gui
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Shelby Labe
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Miguel T Teixeira
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Steven T Morozowich
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, AZ
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Li Y, Huang J, Zhang R, Wang S, Cheng X, Zhang P, Zhai K, Wang W, Liu D, Gao B. Establishment of a venovenous extracorporeal membrane oxygenation in a rat model of acute respiratory distress syndrome. Perfusion 2023; 38:85-91. [PMID: 34378461 DOI: 10.1177/02676591211031468] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Venovenous extracorporeal membrane oxygenation (VV ECMO) is now considered a reasonable option to salvage acute respiratory distress syndrome (ARDS). However, we lack a rodent model for experimental studies. This study was undertaken to establish an animal model of VV ECMO in ARDS rats. METHODS A total of 18 Sprague-Dawley (SD) rats (350 ± 50 g) were used in this study. Using a rat model of oleic acid (OA)-induced ARDS, VV ECMO was established through cavoatrial cannulation of the right jugular vein for venous drainage and venous reinfusion with a specially designed three-cavity catheter. Continuous arterial pressure monitoring was implemented by using a catheter through cannulation of the right femoral artery. The central temperature was monitored with a rectal probe. Arterial blood gas monitoring was implemented by a blood gas analyzer at three-time points: at baseline, 1-hour (after OA modeling), and 3.5-hour (after VV ECMO support). Lung tissue and bronchoalveolar lavage fluid were harvested respectively for protein concentration and pulmonary histologic evaluation to confirm the alleviation of lung injury during VV ECMO. RESULTS Following ARDS induced by OA, ten rats were successfully established on VV ECMO without failure and survived the ECMO procedure. VV ECMO alleviated lung injury and restored adequate circulation for the return of lung function and oxygenation. VV ECMO was associated with decreased lung injury score, wet/dry weight ratio, and fluid leakage into airspaces. CONCLUSION We have established a reliable, economical, and functioning ARDS rat model of VV ECMO.
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Affiliation(s)
- Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Jian Huang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Rongzhi Zhang
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Shixiong Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Xingdong Cheng
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Pengbin Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Kerong Zhai
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Wei Wang
- Department of Cardiopulmonary Bypass, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Debin Liu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China.,Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
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Right Ventricular Injury Increases Mortality in Patients With Acute Respiratory Distress Syndrome on Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. ASAIO J 2023; 69:e14-e22. [PMID: 36375040 DOI: 10.1097/mat.0000000000001854] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular injury (RVI) in the context of acute respiratory distress syndrome (ARDS) is well recognized as an important determinant risk factor of mortality. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is part of the algorithm for the management of patients with severe ARDS and severely impaired gas exchange. Although VV-ECMO may theoretically protect the RV it is uncertain to what degree RVI persists despite VV-ECMO support, and whether it continues to influence mortality after ECMO initiation. The aim of this systematic review and meta-analysis was to investigate the impact of RVI on mortality in this context, testing the hypothesis that RVI worsens mortality in this cohort. We performed a systematic search that identified seven studies commenting on RVI and mortality in patients with ARDS receiving VV-ECMO. The presence of RVI was associated with greater mortality overall (odds ratios [OR]: 2.72; 95% confidence intervals [CI]: 1.52-4.85; p < 0.00) and across three subgroups (RV dilatational measures: OR: 3.51; 95% CI: 1.51-8.14; p < 0.01, RV functional measures: OR: 1.84; 95% CI: 0.99-3.42; p = 0.05, RV measurements post-ECMO initiation: OR: 1.94; 95% CI: 1.01-3.72; p < 0.05). Prospective studies are needed to investigate the causal relationship between RVI and mortality in this patient group and the best management strategies to reduce mortality.
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Complications Associated With Venovenous Extracorporeal Membrane Oxygenation-What Can Go Wrong? Crit Care Med 2022; 50:1809-1818. [PMID: 36094523 DOI: 10.1097/ccm.0000000000005673] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Despite increasing use and promising outcomes, venovenous extracorporeal membrane oxygenation (V-V ECMO) introduces the risk of a number of complications across the spectrum of ECMO care. This narrative review describes the variety of short- and long-term complications that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complications. DATA SOURCES English language articles were identified in PubMed using phrases related to V-V ECMO, acute respiratory distress syndrome, severe respiratory failure, and complications. STUDY SELECTION Original research, review articles, commentaries, and published guidelines from the Extracorporeal Life support Organization were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS Selecting patients for V-V ECMO exposes the patient to a number of complications. Adequate knowledge of these risks is needed to weigh them against the anticipated benefit of treatment. Timing of ECMO initiation and transfer to centers capable of providing ECMO affect patient outcomes. Choosing a configuration that insufficiently addresses the patient's physiologic deficit leads to consequences of inadequate physiologic support. Suboptimal mechanical ventilator management during ECMO may lead to worsening lung injury, delayed lung recovery, or ventilator-associated pneumonia. Premature decannulation from ECMO as lungs recover can lead to clinical worsening, and delayed decannulation can prolong exposure to complications unnecessarily. Short-term complications include bleeding, thrombosis, and hemolysis, renal and neurologic injury, concomitant infections, and technical and mechanical problems. Long-term complications reflect the physical, functional, and neurologic sequelae of critical illness. ECMO can introduce ethical and emotional challenges, particularly when bridging strategies fail. CONCLUSIONS V-V ECMO is associated with a number of complications. ECMO selection, timing of initiation, and management decisions impact the presence and severity of these potential harms.
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Morales Castro D, Abdelnour-Berchtold E, Urner M, Dragoi L, Cypel M, Fan E, Douflé G. Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients. J Cardiothorac Vasc Anesth 2022; 36:4296-4304. [PMID: 36038441 PMCID: PMC9338225 DOI: 10.1053/j.jvca.2022.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVES A paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19. DESIGN Single-center retrospective cohort study. SETTING The study took place in the intensive care unit of an academic tertiary center. PARTICIPANTS The authors included 107 patients with confirmed SARS-CoV-2 infection who underwent bedside venovenous ECMO (VV ECMO) cannulation under TEE guidance between May 2020 and June 2021. INTERVENTIONS TEE-guided bedside VV ECMO cannulation. MEASUREMENTS Patient characteristics, physiologic and ventilatory parameters, and echocardiographic findings were analyzed. The primary outcome was the number of successful TEE-guided bedside cannulations without complications. The secondary outcomes were cannulation complications, frequency of cannula repositioning, and TEE-related complications. MAIN RESULTS TEE-guided cannulation was successful in 99% of the patients. Initial cannula position was adequate in all but 1 patient. Fourteen patients (13%) required cannula repositioning during ECMO support. Forty-five patients (42%) had right ventricular systolic dysfunction, and 9 (8%) had left ventricular systolic dysfunction. Twelve patients (11%) had intracardiac thrombi. One superficial arterial injury and 1 pneumothorax occurred. No pericardial tamponade, hemothorax or intraabdominal bleeding occurred in the authors' cohort. No TEE-related complications or COVID-19 infection of healthcare providers were reported during this study. CONCLUSIONS Bedside TEE guidance for VV ECMO cannulation is safe in patients with severe respiratory failure due to COVID-19. No tamponade or hemothorax, nor TEE-related complications were observed in the authors' cohort.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | | | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Marcelo Cypel
- Department of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada,Department of Medicine, University of Toronto, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada.
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40
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Hodgson CL, Higgins AM, Bailey MJ, Anderson S, Bernard S, Fulcher BJ, Koe D, Linke NJ, Board JV, Brodie D, Buhr H, Burrell AJC, Cooper DJ, Fan E, Fraser JF, Gattas DJ, Hopper IK, Huckson S, Litton E, McGuinness SP, Nair P, Orford N, Parke RL, Pellegrino VA, Pilcher DV, Sheldrake J, Reddi BAJ, Stub D, Trapani TV, Udy AA, Serpa Neto A. Incidence of death or disability at 6 months after extracorporeal membrane oxygenation in Australia: a prospective, multicentre, registry-embedded cohort study. THE LANCET. RESPIRATORY MEDICINE 2022; 10:1038-1048. [PMID: 36174613 DOI: 10.1016/s2213-2600(22)00248-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment. METHODS This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov, NCT03793257. FINDINGS Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] -32% [95% CI -49 to -15]; p<0·001) but not VA-ECMO (VA-ECMO vs eCPR -8% [-22 to 6]; p=0·27). INTERPRETATION In our study, only a third of patients were alive without moderate-to-severe disability at 6 months after initiation of ECMO. The finding that disability was common across all areas of functioning points to the need for long-term, multidisciplinary care and support for surviving patients who have had ECMO. Further studies are needed to understand the 180-day and longer-term prognosis of patients with different diagnoses receiving different modes of ECMO, which could have important implications for the selection of patients for ECMO and management strategies in the ICU. FUNDING The National Health and Medical Research Council of Australia.
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael J Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Shannah Anderson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Stephen Bernard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Bentley J Fulcher
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Denise Koe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Natalie J Linke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jasmin V Board
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, NY, USA; New York-Presbyterian Hospital, New York, NY, USA
| | - Heidi Buhr
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John F Fraser
- School of Medicine, University of Queensland, St Lucia, QLD, Australia; Critical Care Research Group, Adult Intensive Care Society, Prince Charles Hospital, Chermside, QLD, Australia
| | - David J Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Ingrid K Hopper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Sue Huckson
- Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Shay P McGuinness
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Medical Research Institute of New Zealand, Wellington, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Priya Nair
- Intensive Care Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Neil Orford
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, University Hospital Geelong, Geelong, VIC, Australia; School of Medicine, Deakin University, Geelong Waurn Ponds, VIC, Australia
| | - Rachael L Parke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Medical Research Institute of New Zealand, Wellington, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - David V Pilcher
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | | | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Tony V Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia; Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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41
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Mingote Á, Marrero García R, Santos González M, Castejón R, Salas Antón C, Vargas Nuñez JA, García-Fernández J. Individualizing mechanical ventilation: titration of driving pressure to pulmonary elastance through Young's modulus in an acute respiratory distress syndrome animal model. Crit Care 2022; 26:316. [PMID: 36258235 PMCID: PMC9578179 DOI: 10.1186/s13054-022-04184-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
Background Mechanical ventilation increases the risk of lung injury (VILI). Some authors propose that the way to reduce VILI is to find the threshold of driving pressure below which VILI is minimized. In this study, we propose a method to titrate the driving pressure to pulmonary elastance in an acute respiratory distress syndrome model using Young’s modulus and its consequences on ventilatory-induced lung injury.
Material and methods 20 Wistar Han male rats were used. After generating an acute respiratory distress syndrome, two groups were studied: (a) standard protective mechanical ventilation: 10 rats received 150 min of mechanical ventilation with driving pressure = 14 cm H2O, tidal volume < 6 mL/kg) and (b) individualized mechanical ventilation: 10 rats received 150 min of mechanical ventilation with an individualized driving pressure according to their Young’s modulus. In both groups, an individualized PEEP was programmed in the same manner. We analyzed the concentration of IL-6, TNF-α, and IL-1ß in BAL and the acute lung injury score in lung tissue postmortem.
Results Global driving pressure was different between the groups (14 vs 11 cm H2O, p = 0.03). The individualized mechanical ventilation group had lower concentrations in bronchoalveolar lavage of IL-6 (270 pg/mL vs 155 pg/mL, p = 0.02), TNF-α (292 pg/mL vs 139 pg/mL, p < 0.01) and IL-1ß (563 pg/mL vs 131 pg/mL, p = 0.05). They presented lower proportion of lymphocytes (96% vs 79%, p = 0.05) as well as lower lung injury score (6.0 points vs 2.0 points, p = 0.02). Conclusion In our model, individualization of DP to pulmonary elastance through Young’s modulus decreases lung inflammation and structural lung injury without a significant impact on oxygenation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04184-w.
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Affiliation(s)
- Álvaro Mingote
- grid.411171.30000 0004 0425 3881Anaesthesia, Critical Care and Pain Unit, Puerta de Hierro Majadahonda Universitary Hospital, Majadahonda. c/Manuel de Falla, 1, 28222 Madrid, Spain ,grid.5515.40000000119578126Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Ramsés Marrero García
- grid.410458.c0000 0000 9635 9413Anaesthesia, Critical Care Department and Pain Unit, Clinic Hospital, Barcelona, Spain
| | - Martín Santos González
- grid.411171.30000 0004 0425 3881Medical and Surgical Research Unit, Puerta de Hierro Majadahonda Universitary Hospital, Madrid, Spain
| | - Raquel Castejón
- Internal Medicine Laboratory, Puerta de Hierro Majadahonda Universitary Hospital Research Institute, Madrid, Spain
| | - Clara Salas Antón
- grid.411171.30000 0004 0425 3881Pathology Unit, Puerta de Hierro Majadahonda Universitary Hospital, Madrid, Spain
| | - Juan Antonio Vargas Nuñez
- grid.411171.30000 0004 0425 3881Internal Medicine Unit, Puerta de Hierro Majadahonda Universitary Hospital, Madrid, Spain ,grid.5515.40000000119578126Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Javier García-Fernández
- grid.411171.30000 0004 0425 3881Anaesthesia, Critical Care and Pain Unit, Puerta de Hierro Majadahonda Universitary Hospital, Majadahonda. c/Manuel de Falla, 1, 28222 Madrid, Spain ,grid.5515.40000000119578126Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
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42
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Combes A, Brodie D, Aissaoui N, Bein T, Capellier G, Dalton HJ, Diehl JL, Kluge S, McAuley DF, Schmidt M, Slutsky AS, Jaber S. Extracorporeal carbon dioxide removal for acute respiratory failure: a review of potential indications, clinical practice and open research questions. Intensive Care Med 2022; 48:1308-1321. [PMID: 35943569 DOI: 10.1007/s00134-022-06796-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is a form of extracorporeal life support (ECLS) largely aimed at removing carbon dioxide in patients with acute hypoxemic or acute hypercapnic respiratory failure, so as to minimize respiratory acidosis, allowing more lung protective ventilatory settings which should decrease ventilator-induced lung injury. ECCO2R is increasingly being used despite the lack of high-quality evidence, while complications associated with the technique remain an issue of concern. This review explains the physiological basis underlying the use of ECCO2R, reviews the evidence regarding indications and contraindications, patient management and complications, and addresses organizational and ethical considerations. The indications and the risk-to-benefit ratio of this technique should now be carefully evaluated using structured national or international registries and large randomized trials.
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Affiliation(s)
- Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France. .,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, boulevard de l'Hôpital, 75013, Paris, France.
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, USA.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York, USA
| | - Nadia Aissaoui
- Assistance publique des hopitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, Paris, France
| | - Thomas Bein
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - Gilles Capellier
- CHU Besançon, Réanimation Médicale, 2500, Besançon, France.,Université de Franche Comte, EA, 3920, Besançon, France.,Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive, Care Research Centre, Monash University, Melbourne, Australia
| | - Heidi J Dalton
- Heart and Vascular Institute and Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA, USA
| | - Jean-Luc Diehl
- Medical Intensive Care Unit and Biosurgical Research Lab (Carpentier Foundation), HEGP Hospital, Assistance Publique-Hôpitaux de Paris-Centre (APHP-Centre), Paris, France.,Université de Paris, INSERM, Innovative Therapies in Haemostasis, 75006, Paris, France
| | - Stefan Kluge
- Department of Intensive Care, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel F McAuley
- Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, UK.,Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Matthieu Schmidt
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Samir Jaber
- PhyMedExp, University of Montpellier, Institut National de La Santé Et de La Recherche Médicale (INSERM), Centre National de La Recherche Scientifique (CNRS), Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France.,Département d'Anesthésie-Réanimation, Hôpital Saint-Eloi, Montpellier Cedex, France
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44
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Franquet N, Pierart J, Defresne A, Joachim S, Fraipont V. Veno-venous Extracorporeal Membrane Oxygenation for pregnant women with Acute Respiratory Distress Syndrome: a narrative review. ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Acute respiratory distress syndrome remains an uncommon condition during pregnancy. In patients with severe acute respiratory distress syndrome, when oxygenation or ventilation cannot be supported sufficiently using best practice conventional mechanical ventilation and additional therapies, veno-venous extracorporeal membrane oxygenation may be considered. In the past two decades, there has been increasing adoption of this technique to support adult patients with refractory acute respiratory distress syndrome. However, its use for the management of pregnant women is rare and remains a challenge. This narrative review addresses acute respiratory distress syndrome and its management during pregnancy, and then focuses on indications, contraindications, challenges, potential complications, and outcomes of the use of veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome in the pregnant patient.
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45
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Lee GJ, Kim MJ, Lee JG, Lee SH. Use of venovenous extracorporeal membrane oxygenation in trauma patients with severe adult respiratory distress syndrome: A retrospective study. Int J Artif Organs 2022; 45:833-840. [PMID: 35918871 DOI: 10.1177/03913988221116649] [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: 11/16/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) has increased, although its survival benefit in trauma patients with severe adult respiratory distress syndrome (ARDS) remains controversial. We investigated the effect of veno-venous (VV)-ECMO on the clinical outcomes of trauma patients with severe ARDS. METHODS This was a retrospective study at a single center comprising trauma patients admitted between January 2013 and December 2017, diagnosed with severe ARDS using the Berlin definition (PaO2/FiO2 ratio ⩽100), in the 7 days following trauma. Patients were managed with VV-ECMO or conventional mechanical ventilation (CMV). The primary outcome was in-hospital mortality (mortality at 60 days); secondary outcomes comprised 28-day mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, ICU-free days, duration of mechanical ventilation (MV), and MV-free days. Propensity score matching was performed to adjust for the baseline differences. RESULTS Sixteen patients (22.5%) were managed with VV-ECMO and 55 were managed with CMV. After matching, the in-hospital mortality rate (43.8% vs 53.1%; p = 0.760), 28-day mortality rate (37.5% vs 31.3%; p = 0.750), median hospital LOS (39.5 vs 36.5 days; p = 0.533), ICU-free days (0 vs 0 days; p = 0.241), and MV-free days (0 vs 0 days; p = 0.272) did not significantly differ between the VV-ECMO and CMV groups. CONCLUSION In-hospital mortality (mortality at 60 days) did not differ significantly between the VV-ECMO and CMV groups. Although the safety of ECMO in trauma patients requires further investigation, VV-ECMO may be considered as a rescue therapy.
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Affiliation(s)
- Gil Jae Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea.,Department of Traumatology, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Myung Jun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hwan Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
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46
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Zochios V, Brodie D, Shekar K, Schultz MJ, Parhar KKS. Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury. Anaesthesia 2022; 77:1137-1151. [PMID: 35864561 DOI: 10.1111/anae.15806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
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Affiliation(s)
- V Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - D Brodie
- Columbia University College of Physicians and Surgeons, New York, NY, USA.,Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - K Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, QLD, Australia
| | - M J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - K K S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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47
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Bleeding and thrombotic events in patients with severe COVID-19 supported with extracorporeal membrane oxygenation: a nationwide cohort study. Intensive Care Med 2022; 48:1039-1052. [PMID: 35829723 DOI: 10.1007/s00134-022-06794-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe bleeding and thrombotic events and their risk factors in patients receiving extracorporeal membrane oxygenation (ECMO) for severe coronavirus disease 2019 (COVID-19) and to evaluate their impact on in-hospital mortality. METHODS The ECMOSARS registry included COVID-19 patients supported by ECMO in France. We analyzed all patients included up to March 31, 2022 without missing data regarding bleeding and thrombotic events. The association of bleeding and thrombotic events with in-hospital mortality and pre-ECMO variables was assessed using multivariable logistic regression models. RESULTS Among 620 patients supported by ECMO, 29% had only bleeding events, 16% only thrombotic events and 20% both bleeding and thrombosis. Cannulation site (18% of patients), ear nose and throat (12%), pulmonary bleeding (9%) and intracranial hemorrhage (8%) were the most frequent bleeding types. Device-related thrombosis and pulmonary embolism/thrombosis accounted for most of thrombotic events. In-hospital mortality was 55.7%. Bleeding events were associated with in-hospital mortality (adjusted odds ratio (adjOR) = 2.91[1.94-4.4]) but not thrombotic events (adjOR = 1.02[0.68-1.53]). Intracranial hemorrhage was strongly associated with in-hospital mortality (adjOR = 13.5[4.4-41.5]). Ventilation duration before ECMO ≥ 7 days and length of ECMO support were associated with bleeding. Thrombosis-associated factors were fibrinogen ≥ 6 g/L and length of ECMO support. CONCLUSIONS In a nationwide cohort of COVID-19 patients supported by ECMO, bleeding incidence was high and associated with mortality. Intracranial hemorrhage incidence was higher than reported for non-COVID patients and carried the highest risk of death. Thrombotic events were less frequent and not associated with mortality. Length of ECMO support was associated with a higher risk of both bleeding and thrombosis, supporting the development of strategies to minimize ECMO duration.
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48
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Inferior Vena Cava Obstruction Complicating Remote Venovenous Extracorporeal Membrane Oxygenation Bridge to Lung Transplantation. Chest 2022; 162:e5-e8. [DOI: 10.1016/j.chest.2022.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/30/2022] [Indexed: 11/17/2022] Open
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49
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Fior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med 2022; 43:417-425. [PMID: 35760300 DOI: 10.1055/s-0042-1749450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.
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Affiliation(s)
- Gabriele Fior
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Zasha F Vazquez Colon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Florida, Shands Children's Hospital, Gainesville, Florida
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, Shands Children's Hospital, Gainesville, University of Florida, Gainesville, Florida
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital and The Wesley Hospital, Uniting Care Hospitals, Brisbane, QLD, Australia
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50
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Tam CW, Shen L, Zeidman AD, Srivastava A, Ivascu NS. Mechanical Circulatory Support: Primer for Consultant Specialists. Clin J Am Soc Nephrol 2022; 17:890-901. [PMID: 35595531 PMCID: PMC9269658 DOI: 10.2215/cjn.13341021] [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: 01/08/2023]
Abstract
Mechanical life support therapies exist in many forms to temporarily replace the function of vital organs. Generally speaking, these tools are supportive therapy to allow for organ recovery but, at times, require transition to long-term mechanical support. This review will examine nonrenal extracorporeal life support for cardiac and pulmonary support as well as other mechanical circulatory support options. This is intended as a general primer and overview to assist nephrologist consultants participating in the care of these critically ill patients who often experience acute renal injury as a result of cardiopulmonary shock and from their exposure to mechanical circulatory support.
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Affiliation(s)
- Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Liang Shen
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | | | - Ankur Srivastava
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Natalia S Ivascu
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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