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Hariri G, Luxey X, Wenger S, Dureau P, Hariri S, Charfeddine A, Lebreton G, Djavidi N, Lancelot A, Duceau B, Bouglé A. Capillary refill time assessment after fluid challenge in patients on venoarterial extracorporeal membrane oxygenation: A retrospective study. J Crit Care 2024; 82:154770. [PMID: 38461658 DOI: 10.1016/j.jcrc.2024.154770] [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: 12/04/2023] [Revised: 01/29/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Monitoring fluid therapy is challenging in patients assisted with Veno-arterial ECMO. The aim of our study was to evaluate the usefulness of capillary refill time to assess the response to fluid challenge in patients assisted with VA-ECMO. METHODS Retrospective monocentric study in a cardiac surgery ICU. We assess fluid responsiveness after a fluid challenge in patients on VA-ECMO. We recorded capillary refill time before and after fluid challenge and the evolution of global hemodynamic parameters. RESULTS A total of 27 patients were included. The main indications for VA-ECMO were post-cardiotomy cardiogenic shock (44%). Thirteen patients (42%) were responders and 14 non-responders (58%). In the responder group, the index CRT decreased significantly (1.7 [1.5; 2.1] vs. 1.2 [1; 1.3] s; p = 0.01), whereas it remained stable in the non-responder group (1.4 [1.1; 2.5] vs. 1.6 [0.9; 1.9] s; p = 0.22). Diagnosis performance of CRT variation to assess response after fluid challenge shows an AUC of 0.68 (p = 0.10) with a sensitivity of 79% [95% CI, 52-92] and a specificity of 69% [95% CI, 42-87], with a threshold at 23%. CONCLUSION In patients treated with VA-ECMO index capillary refill time is a reliable tool to assesses fluid responsiveness. SPECIALTY Critical care, Cardiac surgery, ECMO.
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Affiliation(s)
- Geoffroy Hariri
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France..
| | - Xavier Luxey
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France
| | - Stefanie Wenger
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Pauline Dureau
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Sarah Hariri
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France
| | - Ahmed Charfeddine
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France
| | - Guillaume Lebreton
- Sorbonne Université, AP-HP, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Nima Djavidi
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Aymeric Lancelot
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Baptiste Duceau
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Adrien Bouglé
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
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Şeren H, Altun Uğraş G, Çam Yanik T. Determining the needs of relatives of patients with a COVID-19 diagnosis in the intensive care unit. Aust Crit Care 2024:S1036-7314(24)00121-8. [PMID: 39054203 DOI: 10.1016/j.aucc.2024.06.008] [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: 04/05/2023] [Revised: 05/10/2024] [Accepted: 06/14/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND The precautions taken in the intensive care unit (ICU) during the COVID-19 pandemic have caused a change in the needs of relatives of patients. OBJECTIVE This research was conducted to determine the needs of relatives of ICU patients diagnosed with COVID-19. METHODS The sample of this cross-sectional study consisted of 68 relatives of patients treated with COVID-19 in the ICU. Data were collected with a "Patient Relatives Information Form", a "Factors Affecting the Needs of the Relatives of Patients in the Intensive Care Unit Form", and the Critical Care Family Needs Inventory (CCFNI). A multivariate and univariate general linear model was used to determine the factors affecting the CCFNI total and subscale scores. Higher CCFNI scores are indicative of higher family need. RESULTS The assurance (3.5 ± 0.4), information (3.4 ± 0.5), proximity (3.0 ± 0.6), comfort (2.8 ± 0.6), and support (2.7 ± 0.5) dimensions were important needs of relatives of patients hospitalised in the ICU. There was a weak negative correlation between participants' ages and CCFNI scores (p = 0.041). According to the univariate general linear model, significant difference was found between the total CCFNI scores (p = 0.032; 95% confidence interval [CI]: 2.68-3.03), based on multivariate general linear model proximity scores (p = 0.000; 95% CI: 2.49-2.91), and support scores (p = 0.029; 95% CI: 2.26-2.68) and the effect of ICU visit restrictions on relatives' anxiety. Additionally, based on the multivariate general linear model, significant difference was found between the assurance scores and the presence of people who provided support to avoid disruption of responsibilities at home (p = 0.025; 95% CI: 3.30-3.54) and between the proximity scores and the expectations of intensive care nurses (p = 0.028; 95% CI: 2.83-3.59). CONCLUSION This study showed that relatives of ICU patients had high levels of needs. Relatives had high needs for assurance and information, whereas their needs for comfort and support were low. As the age of patients' relatives increased, their levels of needs decreased. Relatives of the patients who received support to help with their obligations at home had increased assurance needs, and those who had anxiety about the ICU visit restrictions had increased proximity and support needs.
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Affiliation(s)
- Hasan Şeren
- Mersin University, Institute of Health Sciences PhD Student, Turkey.
| | - Gülay Altun Uğraş
- Mersin University, Faculty of Nursing, Department of Surgical Nursing, Ciftlikkoy Campus, 33343, Yenisehir, Mersin, Turkey.
| | - Tuğba Çam Yanik
- Mersin University, Faculty of Nursing, Department of Surgical Nursing, Ciftlikkoy Campus, 33343, Yenisehir, Mersin, Turkey.
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de Roux Q, Disli Y, Bougouin W, Renaudier M, Jendoubi A, Merle JC, Delage M, Picard L, Sayagh F, Cherait C, Folliguet T, Quesnel C, Becq A, Mongardon N. Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support. Ann Intensive Care 2024; 14:104. [PMID: 38958791 PMCID: PMC11222359 DOI: 10.1186/s13613-024-01326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients. MATERIALS AND METHODS A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation. RESULTS A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042). CONCLUSION UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.
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Affiliation(s)
- Quentin de Roux
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France.
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France.
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, CHU Henri Mondor, 1 rue Gustave Eiffel, Créteil, 94000, France.
| | - Yekcan Disli
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Wulfran Bougouin
- Réanimation polyvalente, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
- AfterROSC research group, Paris, France
| | - Marie Renaudier
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Ali Jendoubi
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Mathilde Delage
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Lucile Picard
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Faiza Sayagh
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Chamsedine Cherait
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, Assistance Publique-Hôpitaux de Paris, DMU CARE, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Christophe Quesnel
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Aymeric Becq
- Service de gastro-entérologie, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
- AfterROSC research group, Paris, France
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Scott EJ, Young S, Ratcliffe SJ, Wang XQ, Mehaffey JH, Sharma A, Rycus P, Tonna J, Yarboro L, Bryner B, Collins M, Teman NR. Venoarterial Extracorporeal Life Support Use in Acute Pulmonary Embolism Shows Favorable Outcomes. Ann Thorac Surg 2024; 118:253-260. [PMID: 38360341 DOI: 10.1016/j.athoracsur.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/04/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Differences in outcomes by indication for venoarterial extracorporeal life support (VA-ECLS) are poorly described. We hypothesized that patients on VA-ECLS for acute pulmonary embolism (PE) have fewer complications and better survival than patients on VA-ECLS for other indications. METHODS All patients ≥18 years on VA-ECLS from the Extracorporeal Life Support Organization global registry (2010-2019) were evaluated (n = 29,842). After excluding patients aged >79 years (n = 729) and those with incomplete indication data (n = 2530), patients were stratified by VA-ECLS indication for PE vs all other indications. The association between being discharged alive and each type of complication with VA-ECLS indication was assessed. RESULTS Of 26,583 patients included in the analysis, 978 (3.7%) were on VA-ECLS for a primary diagnosis of acute PE. Acute PE patients were younger (53.1 vs 56.7 years, P < .001) and were more likely to be women (52.1% vs 32.3%, P < .001). Patients who underwent VA-ECLS for acute PE were 78% more likely to be discharged alive vs patients supported with VA-ECLS for other reasons (52.8% vs 40.4%; P < .001). Acute PE patients had fewer cardiovascular and renal complications (26.6% vs 38.0% and 31.1% vs 39.4%, respectively; adjusted P < .001). Acute PE patients had higher odds of having clots and mechanical complications (8.7% vs 7.9% and 16.7% vs 14.6%, respectively; adjusted P < .001). CONCLUSIONS Patients undergoing VA-ECLS for acute PE have higher odds of survival to hospital discharge compared with those supported for other indications. Additionally, VA-ECLS in this population is associated with fewer cardiovascular and renal complications but higher mechanical complications.
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Affiliation(s)
- Erik J Scott
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Steven Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Xin-Qun Wang
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Aditya Sharma
- Division of Vascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Joseph Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Leora Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Ben Bryner
- Division of Cardiovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Michael Collins
- Department of Thoracic and Cardiovascular Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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Xi Y, Li Y, Wang H, Sun A, Deng X, Chen Z, Fan Y. Effect of veno-arterial extracorporeal membrane oxygenation lower-extremity cannulation on intra-arterial flow characteristics, oxygen content, and thrombosis risk. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 251:108204. [PMID: 38728829 DOI: 10.1016/j.cmpb.2024.108204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE This study aimed to investigate the effects of lower-extremity cannulation on the intra-arterial hemodynamic environment, oxygen content, blood damage, and thrombosis risk under different levels of veno-arterial (V-A) ECMO support. METHODS Computational fluid dynamics methods were used to investigate the effects of different levels of ECMO support (ECMO flow ratios supplying oxygen-rich blood 100-40 %). Flow rates and oxygen content in each arterial branch were used to determine organ perfusion. A new thrombosis model considering platelet activation and deposition was proposed to determine the platelet activation and thrombosis risk at different levels of ECMO support. A red blood cell damage model was used to explore the risk of hemolysis. RESULTS Our study found that partial recovery of cardiac function improved the intra-arterial hemodynamic environment, with reduced impingement of the intra-arterial flow field by high-velocity blood flow from the cannula, a flow rate per unit time into each arterial branch closer to physiological levels, and improved perfusion in the lower extremities. Partial recovery of cardiac function helps reduce intra-arterial high shear stress and residence time, thereby reducing blood damage. The overall level of hemolysis and platelet activation in the aorta decreased with the gradual recovery of cardiac contraction function. The areas at high risk of thrombosis under V-A ECMO femoral cannulation support were the aortic root and the area distal to the cannula, which moved to the descending aorta when cardiac function recovered to 40-60 %. However, with the recovery of cardiac contraction function, hypoxic blood pumped by the heart is insufficient in supplying oxygen to the front of the aortic arch, which may result in upper extremity hypoxia. CONCLUSION We developed a thrombosis risk prediction model applicable to ECMO cannulation and validated the model accuracy using clinical data. Partial recovery of cardiac function contributed to an improvement in the aortic hemodynamic environment and a reduction in the risk of blood damage; however, there is a potential risk of insufficient perfusion of oxygen-rich blood to organs.
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Affiliation(s)
- Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Hongyu Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Anqiang Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Xiaoyan Deng
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China.
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China.
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Murphy S, Flatley M, Piper L, Mason P, Sams V. Indications and Outcomes for Adult Extracorporeal Membrane Oxygenation at a Military Referral Facility. Mil Med 2024:usae189. [PMID: 38743578 DOI: 10.1093/milmed/usae189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/22/2024] [Accepted: 04/01/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Extracorporeal life support, including extracorporeal membrane oxygenation (ECMO), is a potentially life-saving adjunct to therapy in patients experiencing pulmonary and/or cardiac failure. The U.S. DoD has only one ECMO center, in San Antonio, Texas. In this study, we aimed to analyze outcomes at this center in order to determine whether they are on par with those reported elsewhere in the literature. MATERIALS AND METHODS In this observational study, we analyzed data from patients treated with ECMO at the only DoD ECMO center between September 2012 and April 2020. The primary outcome was survival to discharge, and secondary outcomes were discharge disposition and incidence of complications. RESULTS One hundred and forty-three patients were studied, with a 70.6% rate of survival to discharge. Of the patients who survived, 32.7% were discharged home; 32.7% were discharged to a rehabilitation facility; and 33.7% were transferred to another hospital, 29.4% of whom were transferred to lung transplant centers. One patient left against medical advice. Incidence of ECMO-related complications were as follows: 64 patients (44.7%) experienced hemorrhagic complications, 80 (55.9%) had renal complications, 61 (42.6%) experienced cardiac complications, 39 (27.3%) had pulmonary complications, and 5 patients (3.5%) experienced limb ischemia. We found that these outcomes were comparable to those reported in the literature. CONCLUSIONS Extracorporeal membrane oxygenation can be an efficacious adjunct in management of critically ill patients who require pulmonary and/or cardiac support. This single-center observational study demonstrated that the DoD's only ECMO center has outcomes comparable with the reported data in Extracorporeal Life Support Organization's registry.
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Affiliation(s)
- Samantha Murphy
- Department of Surgery, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Meaghan Flatley
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Lydia Piper
- Department of Surgery, Landstuhl Regional Medical Center, Landstuhl 66849, Germany
| | - Phillip Mason
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Valerie Sams
- Department of Surgery, Division of Trauma and Surgical Critical Care, The University of Cincinnati Medical Center, Cincinnati, OH 45219, USA
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Messika J, Eloy P, Boulate D, Charvet A, Fessler J, Jougon J, Lacoste P, Mercier O, Portran P, Roze H, Sage E, Thes J, Tronc F, Vourc'h M, Montravers P, Castier Y, Mal H, Mordant P. Protocol for venoarterial ExtraCorporeal Membrane Oxygenation to reduce morbidity and mortality following bilateral lung TransPlantation: the ECMOToP randomised controlled trial. BMJ Open 2024; 14:e077770. [PMID: 38448059 PMCID: PMC10916175 DOI: 10.1136/bmjopen-2023-077770] [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: 07/17/2023] [Accepted: 02/02/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Lung transplantation (LTx) aims at improving survival and quality of life for patients with end-stage lung diseases. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used as intraoperative support for LTx, despite no precise guidelines for its initiation. We aim to evaluate two strategies of VA-ECMO initiation in the perioperative period in patients with obstructive or restrictive lung disease requiring bilateral LTx. In the control 'on-demand' arm, high haemodynamic and respiratory needs will dictate VA-ECMO initiation; in the experimental 'systematic' arm, VA-ECMO will be pre-emptively initiated. We hypothesise a 'systematic' strategy will increase the number of ventilatory-free days at day 28. METHODS AND ANALYSIS We designed a multicentre randomised controlled trial in parallel groups. Adult patients with obstructive or restrictive lung disease requiring bilateral LTx, without a formal indication for pre-emptive VA-ECMO before LTx, will be included. Patients with preoperative pulmonary hypertension with haemodynamic collapse, ECMO as a bridge to transplantation, severe hypoxaemia or hypercarbia will be secondarily excluded. In the systematic group, VA-ECMO will be systematically implanted before the first pulmonary artery cross-clamp. In the on-demand group, VA-ECMO will be implanted intraoperatively if haemodynamic or respiratory indices meet preplanned criteria. Non-inclusion, secondary exclusion and VA-ECMO initiation criteria were validated by a Delphi process among investigators. Postoperative weaning of ECMO and mechanical ventilation will be managed according to best practice guidelines. The number of ventilator-free days at 28 days (primary endpoint) will be compared between the two groups in the intention-to-treat population. Secondary endpoints encompass organ failure occurrence, day 28, day 90 and year 1 vital status, and adverse events. ETHICS AND DISSEMINATION The sponsor is the Assistance Publique-Hôpitaux de Paris. The ECMOToP protocol version 2.1 was approved by Comité de Protection des Personnes Ile de France VIII. Results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT05664204.
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Affiliation(s)
- Jonathan Messika
- Service de Pneumologie B et Transplantation Pulmonaire, APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Paris, France
- Physiopathology and Epidemiology of Respiratory Diseases, UMR1152, INSERM and Université de Paris, Paris, France
- Paris Transplant Group, Paris, France
| | - Philippine Eloy
- Département d'épidémiologie, Biostatistiques et Recherche Clinique, Hôpital Bichat, AP-HP Nord, Université de Paris, Hôpital Bichat Claude-Bernard, Paris, France
- INSERM CIC-EC1425, Hôpital Bichat, Paris, France
| | - David Boulate
- Service de chirurgie thoracique, des maladies de l'œsophage et de transplantation pulmonaire, Assistance Publique Hopitaux de Marseille, Hôpital Nord, Marseille, France
| | - Aude Charvet
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
- Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Jacques Jougon
- Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University, Pessac, France
| | - Philippe Lacoste
- Service de chirurgie thoracique et cardiovasculaire, CHU Nantes, Nantes, France
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Groupe Hospitalier Paris-Saint Joseph, Le Plessis Robinson, France
| | - Philippe Portran
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Hadrien Roze
- Department of Anesthesiology and Critical Care, Haut-Leveque Hospital, Bordeaux University Hospital, Pessac, France
| | - Edouard Sage
- Department of Thoracic Surgery and Lung Transplantation, Hopital Foch, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Jacques Thes
- Department of Anesthesiology, Hôpital Marie-Lannelongue, Groupe hospitalier Paris-Saint Joseph, Le Plessis-Robinson, France
- Cardiothoracic Intensive Care Unit, Hôpital Marie-Lannelongue, Groupe Hospitalier Paris-Saint Joseph, Le Plessis-Robinson, France
| | - Francois Tronc
- Service de chirurgie thoracique, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard, Lyon 1, Lyon, France
| | - Mickael Vourc'h
- Service d'Anesthésie-Réanimation Chirurgie Cardiaque, Hôpital Laennec, CHU de Nantes, Nantes, France
- INSERM CIC 0004 Immunologie et Infectiologie, Université de Nantes, Nantes, France
| | - Philippe Montravers
- Unité INSERM UMR 1152, UFR de Médecine Xavier Bichat, Paris, France
- Département d'Anesthésie et Réanimation, DMU PARABOL, APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Yves Castier
- Physiopathology and Epidemiology of Respiratory Diseases, UMR1152, INSERM and Université de Paris, Paris, France
- Service de Chirurgie Vasculaire, Thoracique et Transplantation, APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Herve Mal
- Service de Pneumologie B et Transplantation Pulmonaire, APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Paris, France
- Physiopathology and Epidemiology of Respiratory Diseases, UMR1152, INSERM and Université de Paris, Paris, France
| | - Pierre Mordant
- Physiopathology and Epidemiology of Respiratory Diseases, UMR1152, INSERM and Université de Paris, Paris, France
- Service de Chirurgie Vasculaire, Thoracique et Transplantation, APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Paris, France
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Veyret S, Girard L, Puech B, Dangers L, Jabot J, Neuschwander A, Braunberger E, Allyn J, Allou N, Vidal C. The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2024; 38:451-458. [PMID: 38185567 DOI: 10.1053/j.jvca.2023.11.025] [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: 06/26/2023] [Revised: 11/07/2023] [Accepted: 11/19/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVES Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality. DESIGN This was a retrospective and observational study. SETTING The study was conducted at a University hospital. PARTICIPANTS This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. METHODS The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. RESULTS A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. CONCLUSIONS In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.
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Affiliation(s)
- Simon Veyret
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Léandre Girard
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Bérénice Puech
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Laurence Dangers
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Julien Jabot
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Arthur Neuschwander
- Service de Réanimation de Chirurgie Cardio-thoracique et Vasculaire, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Eric Braunberger
- Service de Chirurgie Cardio-thoracique et Vasculaire, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Jérôme Allyn
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Nicolas Allou
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Charles Vidal
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France.
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Fischer MO, Guinot PG, Mallat J. Heading toward a personalized approach for ECMO patient management. Anaesth Crit Care Pain Med 2024; 43:101325. [PMID: 37952728 DOI: 10.1016/j.accpm.2023.101325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Marc-Olivier Fischer
- Institut Aquitain du Cœur, Clinique Saint Augustin, Elsan, 114 avenue d'Arès, Bordeaux Cedex, 33 074, France.
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, 21000, Dijon, France
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Yu A, Zhang M, Wang Y, Yan L, Guo C, Deng J, Xiong J. Health-related quality of life assessment instruments for extracorporeal membrane oxygenation survivors: A scoping review. Perfusion 2023:2676591231211518. [PMID: 37934027 DOI: 10.1177/02676591231211518] [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: 11/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has been successfully and widely used in adult patients for the past 5 years. About 50% of these patients can survive and are discharged from hospitals. Health-related quality of life (HRQOL) is crucial for evaluating survived ECMO patients. This scoping review aims to identify instruments commonly used to measure HRQOL of ECMO survivors and give pertinent instrument characteristics. METHODS A systematic search was conducted in PubMed, Web of Science, EMBASE (OVID), MEDLINE (OVID), CINAHL (EBSCO), Cochrane Library, and three Chinese databases from January 2012 to December 2021. Two reviewers independently reviewed publication selection and data extraction. RESULTS Twenty-nine studies met the inclusion criteria. Most studies (93%) were cross-sectional, and the median (or average) follow-up time ranged from 3 months to 9 years. Two prospective studies (7%) followed patients longitudinally until 1 year after discharge. ECMO survivors had poorer long-term HRQOL than the general population. However, it is comparable to or better than patients with other critical or chronic illnesses. Identified HRQOL assessment instruments show four generic HRQOL instruments, one disease-specific HRQOL instrument, and nineteen single-dimensional instruments. Seven instruments were used in more than three articles. SF-36 (86.2%), IES/IES-R (41.4%), and HADS (37.9%) were the most frequently used instruments. CONCLUSION The timing, frequency, and tools for HRQOL assessment of ECMO survivors are variable. No ECMO-specific HRQOL instrument was developed and validated. Further studies on assessment instruments are warranted. Research is also needed to identify interventions that may enhance HRQOL in ECMO survivors.
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Affiliation(s)
- Anqi Yu
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng Zhang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Wang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Yan
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Chunling Guo
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Juan Deng
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jie Xiong
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Deng J, Zeng Z, Zhang Z. Case report of non-tracheal intubation-an alternative for postpneumonectomy patients undergoing contralateral pulmonary resection. J Cardiothorac Surg 2023; 18:282. [PMID: 37817241 PMCID: PMC10565958 DOI: 10.1186/s13019-023-02386-z] [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: 03/01/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Surgery on the contralateral or other lungs after pneumonectomy on one side is highly challenging and complex. It is critical to creating conditions for fluent surgical maneuvers while ensuring adequate ventilation for a patient during such an operation in the same chest cavity that appears incompatible. CASE PRESENTATION We have reported herein the case of a patient who, following a left pneumonectomy, underwent a right upper pulmonary nodule wedge resection via video-assisted thoracoscopic surgery without requiring endotracheal intubation. We managed ventilation with a laryngeal mask airway under general anesthesia combined with a thoracic epidural block. The diseased lobe collapsed well for the surgical procedure during VATS without hypoxia, after which the resection was safely performed. CONCLUSIONS Non-tracheal intubation anesthesia can be a potentially attractive alternative for patients undergoing contralateral pulmonary resection after pneumonectomy.
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Affiliation(s)
- Jingdan Deng
- Department of Anesthesiology, Meizhou People's Hospital, 514031, Meizhou City, Guangdong Province, China.
| | - Zhiwen Zeng
- Department of Anesthesiology, Meizhou People's Hospital, 514031, Meizhou City, Guangdong Province, China
| | - Zizheng Zhang
- Department of thoracic surgery, Meizhou People's Hospital, 514031, Meizhou City, Guangdong Province, China
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12
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Wang J, Wang S, Song Y, Huang M, Cao W, Liu S, Chen S, Li X, Liu M, He Y. Analysis of 24-hour Death Risk Factors in Circulatory Failure Patients Treated with Venoarterial Extracorporeal Membrane Oxygenation. Braz J Cardiovasc Surg 2023; 38:e20220398. [PMID: 37801399 PMCID: PMC10550103 DOI: 10.21470/1678-9741-2022-0398] [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: 04/01/2022] [Accepted: 12/27/2022] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE To explore the factors affecting short-term prognosis of circulatory failure patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) treatment. METHODS A total of 136 patients undergoing VA-ECMO were enrolled in this study and subsequently divided into the death group (n=35) and the survival group (n=101) based on whether death occurred during hospitalisation. Extracorporeal membrane oxygenation (ECMO) running time, length of intensive care unit stay, length of hospital stay, costs, and ECMO complications were then compared between the two groups. RESULTS The average age of all patients undergoing ECMO was 47.64±16.78 years (53.2±16.20 years in the death group and 45.713±16.62 years in the survival group) (P=0.022). Patients in the survival group exhibited a clear downward trend in lactic acid value following ECMO treatment compared to those in the death group. Total hospitalisation stay was longer in the survival group (35 days) than in the death group (15.5 days) (P<0.001). In the analysis of ECMO complications, the incidence of neurological complications, renal failure, limb complications, and infection were higher in the death group than in the survival group (P<0.05 for all). Specifically, as a risk factor for patient survival and discharge, the occurrence of infection will lead to increased hospitalisation stays and costs (P<0.05 for both). CONCLUSION Complications such as kidney failure and infection are associated with in-hospital death, and ECMO-related complications should be actively prevented to improve the survival rate of VA-ECMO treatment.
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Affiliation(s)
- Jianwei Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
- Department of Critical Care Medicine, Puyang People’s Hospital,
Henan, People’s Republic of China
| | - Shengshu Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
| | - Yang Song
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - MingJun Huang
- Department of Extracorporeal Support Center, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Wenzhe Cao
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shaohua Liu
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shimin Chen
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Xuehang Li
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Miao Liu
- Department of Statistics and Epidemiology, Graduate School, Chinese
People’s Liberation Army General Hospital, Beijing, People’s Republic of China
| | - Yao He
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- State Key Laboratory of Kidney Diseases, Beijing, People’s Republic
of China
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Savaş H, Guler S. Prevention of catheter-related bloodstream infections in patients with extracorporeal membrane oxygenation: a literature review. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230491. [PMID: 37729228 PMCID: PMC10511280 DOI: 10.1590/1806-9282.20230491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/22/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Hafize Savaş
- Lokman Hekim University, Faculty of Health Sciences, Nursing Department – Ankara, Turkey
| | - Sevil Guler
- Gazi University, Faculty of Nursing – Ankara, Turkey
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Khanduja S, Kim J, Kang JK, Feng CY, Vogelsong MA, Geocadin RG, Whitman G, Cho SM. Hypoxic-Ischemic Brain Injury in ECMO: Pathophysiology, Neuromonitoring, and Therapeutic Opportunities. Cells 2023; 12:1546. [PMID: 37296666 PMCID: PMC10252448 DOI: 10.3390/cells12111546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), in conjunction with its life-saving benefits, carries a significant risk of acute brain injury (ABI). Hypoxic-ischemic brain injury (HIBI) is one of the most common types of ABI in ECMO patients. Various risk factors, such as history of hypertension, high day 1 lactate level, low pH, cannulation technique, large peri-cannulation PaCO2 drop (∆PaCO2), and early low pulse pressure, have been associated with the development of HIBI in ECMO patients. The pathogenic mechanisms of HIBI in ECMO are complex and multifactorial, attributing to the underlying pathology requiring initiation of ECMO and the risk of HIBI associated with ECMO itself. HIBI is likely to occur in the peri-cannulation or peri-decannulation time secondary to underlying refractory cardiopulmonary failure before or after ECMO. Current therapeutics target pathological mechanisms, cerebral hypoxia and ischemia, by employing targeted temperature management in the case of extracorporeal cardiopulmonary resuscitation (eCPR), and optimizing cerebral O2 saturations and cerebral perfusion. This review describes the pathophysiology, neuromonitoring, and therapeutic techniques to improve neurological outcomes in ECMO patients in order to prevent and minimize the morbidity of HIBI. Further studies aimed at standardizing the most relevant neuromonitoring techniques, optimizing cerebral perfusion, and minimizing the severity of HIBI once it occurs will improve long-term neurological outcomes in ECMO patients.
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Affiliation(s)
- Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Jiah Kim
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Cheng-Yuan Feng
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Melissa Ann Vogelsong
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Romergryko G. Geocadin
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
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McIntyre A, Schroder G, Amadi A, Jimenez M, Marflak J, Dell'Aiera L, Fitzgerald D. A quality improvement initiative to increase adult ECMO decision-making abilities in a perfusion education program: The use of 3D ECMO simulation. Perfusion 2023:2676591231177903. [PMID: 37227090 DOI: 10.1177/02676591231177903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Adult and pediatric ECMO procedures have been increasingly established as conventional life-saving modalities in critical care services across the world. Since 2017, a multidisciplinary team of program advisors for our perfusion education program have aimed to increase cardiovascular perfusion (CVP) student ECMO exposure and improve clinical decision-making. In this QI intervention, the use of 3D computer-based simulation was assessed in establishing a standardized process to improve the diagnosis and treatment of adult ECMO complications among first year CVP students. METHODS The Califia 3D Patient Simulator was incorporated into the curriculum for first year CVP students (n = 26) along with traditional lecture for the adult ECMO complication laboratory session. Pre-class knowledge assessments using de-identified polling software were compared to post-class assessments following the first assigned learning activity. Assessments from students that received simulation before lecture (SIM, n = 15) were compared to students receiving lecture before simulation (LEC, n = 11). User experience questionnaires (UEQ) consisting of 26 questions for six scales of simulation instruction were administered to measure the comprehensive impression of the student experience. RESULTS Overall median [IQR] pre- and -post knowledge assessment scores were 74% [11] and 84% [11], respectively (p = 0.01). There were no significant differences in pre-class assessment scores between the SIM and LEC groups (74.0% and 74.0%, respectively, p = 0.959). The LEC group achieved higher median post-assessment scores than the SIM group (84% vs 79%, p = 0.032). Among the 26 UEQ survey scales, 23 were positively evaluated (>0.8), and three were a neutral evaluation (-0.8 to 0.8). Cronbach Alpha-Coefficients of >0.78 were measured for attractiveness, perspicuity, efficacy, and stimulation. The coefficient for dependability was 0.37. 25 (96.2%) students indicated that 3D simulation was beneficial to improving ECMO clinical decision-making. CONCLUSIONS In this QI intervention, the implementation of computer-based 3D simulation following lecture was perceived by learners to help improve the diagnosis and treatment of ECMO-related complications.
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Affiliation(s)
- Angela McIntyre
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Garrett Schroder
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Adannaya Amadi
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Jimenez
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - John Marflak
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Laura Dell'Aiera
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
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Alnahhal KI, Majumdar M, Irshad A, Kapur N, Kumar S, Salehi P. Peripheral artery disease and extracorporeal membrane oxygenation: Examining a high-risk cohort over time. Vascular 2023:17085381231165825. [PMID: 36943022 DOI: 10.1177/17085381231165825] [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: 03/23/2023]
Abstract
OBJECTIVE Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a resource-intensive approach for the management of refractory cardiogenic shock. Within this population exists a substantial cohort of patients with peripheral artery disease (PAD), which independently increases the risk of complications and all-cause mortality. We studied 10-year national trends of the impact of PAD among VA-ECMO recipients to better understand the prevalence of PAD and implications on outcomes in this vulnerable population. METHODS This 10-year retrospective, propensity score-matched study identified all adult patients (≥18) who underwent VA-ECMO between 2009 and 2018, from a large US database (National Inpatient Sample). Patients with an ICD diagnosis of PAD were identified. The primary endpoints of in-hospital mortality, bleeding complications and major limb loss (above- or below-knee amputation) were compared between patients with PAD to those without. RESULTS A total of 6768 patients were identified, of which 342 (5.3%) had PAD. The median age at admission was significantly higher in PAD patients [64 years vs. 55 years; p < .01], as was male gender [71% vs. 64%; p < .01]. Patients with PAD had higher rates of smoking (38.9% vs. 23.3%), hypertension (71.1% vs. 50%), diabetes (37.4% vs. 27.0%), chronic kidney disease (30.1% vs. 18.0%), coronary artery disease (76.0% vs. 35.0%) and dyslipidemia (76.0% vs. 35.0); all p < .01. After propensity-matching 2:1 for comorbidities, PAD patients were found to have significantly greater overall complications, including in-hospital mortality, bleeding, surgical wound infections, pseudoaneurysms, and major adverse limb events [71.9% vs. 63.9%; p < .01]. Subgroup analysis revealed greater in-hospital mortality [62.2% vs. 55.3%; p < .05], major amputations [4.1% vs. 0.3%; p < .01] and blood transfusions [32.2% vs. 26.2%; p < .05] in PAD patients. Over 2014-2018, the non-PAD group demonstrated statistically discernable trends in a 51.1% decrease in overall complications and a 28.1% increase in survival to discharge (all p < .01). Over the same time period the PAD cohort experienced a modest, nonsignificant, decrease in complications [7.0%, p = .40] and a decrease in those surviving to discharge [47.1% vs. 40.5%, p = .91]. CONCLUSION Patients with PAD on VA-ECMO are sicker at baseline and experience significantly greater major amputations and higher in-hospital mortality. They have not benefitted from the considerable decrease in complication rates and increase in survival to discharge over time as compared to their non-PAD counterparts. These findings demonstrate the substantial frailty of the PAD population within an already high-risk cohort, and highlight the need for better procedural approaches and innovative technologies.
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Affiliation(s)
| | - Monica Majumdar
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Ali Irshad
- The CardioVascular Center, 1867Tufts Medical Center, Boston MA, USA
| | - Navin Kapur
- The CardioVascular Center, 1867Tufts Medical Center, Boston MA, USA
| | - Shivani Kumar
- The CardioVascular Center, 1867Tufts Medical Center, Boston MA, USA
| | - Payam Salehi
- The CardioVascular Center, 1867Tufts Medical Center, Boston MA, USA
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17
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Reid TD, Kratzke I, Dayal D, Raff L, Serrano P, Kumar A, Boddie O, Zendel A, Gallaher J, Carlson R, Boone J, Charles AG, Desai CS. The role of extracorporeal membrane oxygenation in adult kidney transplant patients: A qualitative systematic review of literature. Artif Organs 2023; 47:24-37. [PMID: 35986612 DOI: 10.1111/aor.14376] [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: 04/20/2022] [Revised: 06/23/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND A paucity of evidence exists regarding the risks and benefits of Extracorporeal Membrane Oxygenation (ECMO) in adult kidney transplantation. METHODS This was a systematic review conducted from Jan 1, 2000 to April 24, 2020 of adult kidney transplant recipients (pre- or post- transplant) and donors who underwent veno-arterial or veno-venous ECMO cannulation. Death and graft function were the primary outcomes, with complications as secondary outcomes. RESULTS Twenty-three articles were identified that fit inclusion criteria. 461 donors were placed on ECMO, with an overall recipient 12-month mortality rate of 1.3% and a complication rate of 61.5%, the majority of which was delayed graft function. Fourteen recipients were placed on ECMO intraoperatively or postoperatively, with infection as the most common indication for ECMO. The 90-day mortality rate for recipients on ECMO was 42.9%, with multisystem organ failure and infection as the ubiquitous causes of death. 35.7% of patients experienced rejection within 6 months of decannulation, yet all were successfully treated. CONCLUSIONS ECMO use in adult kidney transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO mirrors that of recipients from standard criteria donors. The morbidity and mortality of recipients placed on ECMO are also similar to other patient populations requiring ECMO.
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Affiliation(s)
- Trista D Reid
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ian Kratzke
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diana Dayal
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Raff
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Pablo Serrano
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aman Kumar
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Olivia Boddie
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alex Zendel
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jared Gallaher
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rebecca Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joshua Boone
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony G Charles
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chirag S Desai
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
The use of extracorporeal membrane oxygenation (ECMO) is growing rapidly in all patient populations, especially adults for both acute lung or heart failure. ECMO is a complex, high risk, resource-intense, expensive modality that requires appropriate planning, training, and management for successful outcomes. This article provides an optimal approach and the basic framework for initiating a new ECMO program, which can be tailored to meet local needs. Setting up a new ECMO program and sustaining it requires institutional commitment, physician champions, multidisciplinary team involvement, ongoing training, and education of the ECMO team personnel and a robust quality assurance program to minimize complications and improve outcomes.
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19
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Developing Cardiothoracic Surgical Critical Care Intensivists: A Case for Distinct Training. Medicina (B Aires) 2022; 58:medicina58121865. [PMID: 36557067 PMCID: PMC9784574 DOI: 10.3390/medicina58121865] [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: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Cardiothoracic surgical critical care medicine is practiced by a diverse group of physicians including surgeons, anesthesiologists, pulmonologists, and cardiologists. With a wide array of specialties involved, the training of cardiothoracic surgical intensivists lacks standardization, creating significant variation in practice. Additionally, it results in siloed physicians who are less likely to collaborate and advocate for the cardiothoracic surgical critical care subspeciality. Moreover, the current model creates credentialing dilemmas, as experienced by some cardiothoracic surgeons. Through the lens of critical care anesthesiologists, this article addresses the shortcomings of the contemporary cardiothoracic surgical intensivist training standards. First, we describe the present state of practice, summarize past initiatives concerning specific training, outline why standardized education is needed, provide goals of such training standardization, and offer a list of desirable competencies that a trainee should develop to become a successful cardiothoracic surgical intensivist.
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20
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Luo JC, Zhang YJ, Hou JY, Luo MH, Liu K, Tu GW, Luo Z. Weaning from venous-arterial extracorporeal membrane oxygenation: The hemodynamic and clinical aspects of flow challenge test. Front Med (Lausanne) 2022; 9:989197. [PMID: 36160169 PMCID: PMC9493013 DOI: 10.3389/fmed.2022.989197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
Abstract
The cardiac function reserve is crucial for the successful weaning of V-A ECMO. During the V-A ECMO weaning phase, the gradual reduction in pump flow converts the blood flow originally driven by the pump to native cardiac output and also transforms afterload (caused by retrograde flow) into ventricular preload, thus introducing a “flow challenge” to the native heart. In this perspective, we propose to use this flow challenge as a test to simulate the preload-to-afterload conversion to assess cardiac functional reserve quantitatively. With this short article we offer the hemodynamic and clinical aspects regarding the flow challenge test.
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Affiliation(s)
- Jing-chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-hao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guo-wei Tu,
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
- Shanghai Key Lab of Pulmonary Inflammation and Injury, Shanghai, China
- Zhe Luo,
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21
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Amin RM, Chaudhry YP, Rao SS, Puvanesarajah V, Best MJ, Etchill E, Hasenboehler EA. Extremity fasciotomy for patients on extracorporeal membrane oxygenation is independently associated with inpatient mortality. Orthop Traumatol Surg Res 2022; 108:103144. [PMID: 34785372 DOI: 10.1016/j.otsr.2021.103144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) maintains end-organ perfusion in critically ill patients with cardiac or respiratory failure; however, ECMO cannulation in the extremities has been associated with significant limb ischemia and risk of compartment syndrome. Current literature on ECMO and fasciotomies is limited to small single-center retrospective studies. This study aimed to (1) compare the incidence of postoperative outcomes and mortality in patients undergoing fasciotomy while on ECMO to those of non-fasciotomy ECMO patients, and (2) assess the difference in adjusted mortality risk between the two groups. HYPOTHESIS We hypothesized that patients undergoing fasciotomy while on ECMO would have significantly higher odds of in-hospital mortality than non-fasciotomy ECMO patients after adjustment for perioperative variables. METHODS We conducted a retrospective review of NIS from January 1st, 2012-September 30, 2015 for all hospitalizations involving ECMO and stratified them into two cohorts based on whether they underwent fasciotomy after ECMO. Patient baseline characteristics, in-hospital procedures, and postoperative outcomes were compared between the two cohorts. Logistic regression was used to assess in-hospital mortality risk between the two cohorts adjusting for age, sex, Elixhauser score, and perioperative procedures and non-fasciotomy perioperative morbidity. RESULTS There were 7,085 estimated eligible discharges between 2012 and 2015 identified, 149 (2.1%) of which underwent fasciotomy following ECMO. One hundred and thirteen of the 149 hospitalizations (77%) in the fasciotomy cohort resulted in in-hospital mortality, compared to 3,805 of the 6,936 (55%) in the non-fasciotomy cohort. There were no differences in rates of transfusion (p=0.290), length of stay (p=0.282), or discharge disposition (p=0.126) between the two cohorts. In the logistic regression model, the fasciotomy cohort had a higher odds of in-hospital mortality than non-fasciotomy cohort (OR, 2.5; 95% CI, 1.1-5.6). DISCUSSION Operative treatment of acute compartment syndrome for patients on ECMO therapy is associated with significantly increased mortality and morbidity. Whether fasciotomy is a marker of sickness or represents a cause-and-effect relationship is unknown and future should investigate the role of non-operative treatment of compartment syndrome on mortality in this population. LEVEL OF EVIDENCE III; Prognostic.
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Affiliation(s)
- Raj M Amin
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Yash P Chaudhry
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Sandesh S Rao
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Eric Etchill
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States.
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22
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Zhang A, De Gala V, Lementowski PW, Cvetkovic D, Xu JL, Villion A. Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review. Cureus 2022; 14:e28234. [PMID: 36158355 PMCID: PMC9488858 DOI: 10.7759/cureus.28234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.
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23
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Wang Q, Zhu J, Chen L, He Y, Li H, Lan Y, Huang C, Peng L. Successful treatment of severe ARDS caused by accidental inhalation of nitric acid fumes with veno-venous ECMO: A case report and literature review. Medicine (Baltimore) 2022; 101:e29447. [PMID: 35905254 PMCID: PMC9333490 DOI: 10.1097/md.0000000000029447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE The treatment of severe acute respiratory distress syndrome caused by accidental inhalation of nitric acid fumes is challenging. Few successful cases have been reported in literature. Owing to the development of extracorporeal life support, extracorporeal membrane oxygenation (ECMO) may play an important role in treatment. PATIENT CONCERNS A 40-year-old man was accidentally exposed to nitric acid fumes for 10 minutes in a factory. Mild throat irritation and dyspnea occurred 3.5 hours after exposure. Severe dyspnea recurred approximately two hours later. Chest computed tomography revealed bilateral interstitial edema. Tracheal intubation and mechanical ventilation were provided when the non-invasive ventilator failed to support the patient. However, his vital signs, respiratory function, and circulation were aggravated. DIAGNOSIS Aspiration pneumonia (inhalation of nitric acid fumes), acute respiratory distress syndrome, and hypertension. INTERVENTIONS Veno-venous ECMO (VV-ECMO) was started 6 hours after exposure at the intensive care unit. During VV-ECMO, hypoxia improved. However, chest radiography revealed aggravated pulmonary edema. Prone positioning under ultrasound monitoring and high-dose methylprednisolone were administered on the first day. Nebulization and fiberoptic bronchoscopy for airway management were performed on the second day after the exposure. Pulmonary secretions were significantly reduced 48 hours later. OUTCOMES The patient was weaned off V-V ECMO after 6 days, achieved the standard of extubation after 9 days, and was discharged without serious pulmonary or infectious complications after 12 days of hospitalization. Three weeks after discharge, the patient's lung function showed a slight decline in the diffusion function. Two months after discharge, the patient's lung function returned to normal. LESSON Early ECMO combined with prone positioning and visualized management through ultrasonography can better improve the prognoses of patients and promote lung function recovery.
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Affiliation(s)
- Qian Wang
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Junchen Zhu
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
- *Correspondence: Lvlin Chen, Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, No.82, North Section 2, 2nd Ring Road, Jinniu District, Chengdu, Sichuan 610081, China (e-mail: , Junchen Zhu: )
| | - Yan He
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Hui Li
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Ying Lan
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Chao Huang
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
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24
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M'Pembele R, Roth S, Metzger A, Nucaro A, Stroda A, Polzin A, Hollmann MW, Lurati Buse G, Huhn R. Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Thromb J 2022; 20:42. [PMID: 35902857 PMCID: PMC9330661 DOI: 10.1186/s12959-022-00401-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The number of patients treated with extracorporeal membrane oxygenation (ECMO) devices is increasing. Anticoagulation therapy is crucial to prevent thrombosis during ECMO therapy. Predominantly, heparin has been used as primary anticoagulant but direct thrombin inhibitors (DTI) have been established as alternatives. The aim of this systematic review and meta-analysis was to evaluate clinical outcomes in patients treated with heparin compared to different DTI during ECMO. METHODS A systematic search was conducted. Full scientific articles were sought for inclusion if heparin anticoagulation was compared to DTI (argatroban/bivalirudin) in ECMO patients. Risk of bias was assessed by Newcastle Ottawa scale. Primary endpoint was in-hospital mortality. Bleeding events, thrombotic events, hours of ECMO support, days of hospital stay, percentage of time within therapeutic range and time to therapeutic range were extracted from full texts as secondary endpoints. Results were presented as Forrest-plots. GRADE was used for confidence assessment in outcomes. RESULTS Systematic search identified 4.385 records, thereof 18 retrospective studies for a total of 1942 patients, complied with the predefined eligibility criteria:15 studies investigated bivalirudin and 3 studies investigated argatroban versus heparin. Risk of bias was high for most studies. In-hospital mortality, major bleeding events and pump-related thrombosis were less frequent in DTI group as compared to heparin [mortality-OR 0.69, 95% CI 0.54-0.86; major bleeding-OR 0.48, 95% CI 0.29-0.81; pump thrombosis-OR 0.55, 95% CI 0.40-0.76]. Additionally, percentage of time within therapeutic range was higher for DTI [SMD 0.54, 95% CI 0.14-0.94]. GRADE approach revealed a very low level of certainty for each outcome. CONCLUSION In this meta-analysis, DTI and especially bivalirudin showed beneficial effects on clinical outcomes in ECMO patients as compared to heparin. However, due to the lack of randomized trials, certainty of evidence is low. TRIAL REGISTRATION This systematic review and meta-analysis was prospectively registered at PROSPERO data base (reference number CRD42021237252 ).
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Affiliation(s)
- René M'Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany.
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Aljoscha Metzger
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Anthony Nucaro
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Amsterdam, The Netherlands
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
- Department of Anesthesiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
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25
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Zeng P, Yang C, Chen J, Fan Z, Cai W, Huang Y, Xiang Z, Yang J, Zhang J, Yang J. Comparison of the Efficacy of ECMO With or Without IABP in Patients With Cardiogenic Shock: A Meta-Analysis. Front Cardiovasc Med 2022; 9:917610. [PMID: 35872892 PMCID: PMC9300857 DOI: 10.3389/fcvm.2022.917610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/24/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Studies on extracorporeal membrane oxygenation (ECMO) with and without an intra-aortic balloon pump (IABP) for cardiogenic shock (CS) have been published, but there have been no meta-analyses that compare the efficacy of these two cardiac support methods. This meta-analysis evaluated the outcomes of these two different treatment measures. Methods The PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials databases were searched until March 2022. Studies that were related to ECMO with or without IABP in patients with CS were screened. Quality assessments were evaluated with the methodological index for nonrandomized studies (MINORS). The primary outcome was in-hospital survival, while the secondary outcomes included duration of ECMO, duration of ICU stay, infection/sepsis, and bleeding. Revman 5.3 and STATA software were used for this meta-analysis. Results In total, nine manuscripts with 2,573 patients were included in the systematic review. CS patients who received ECMO in combination with IABP had significantly improved in-hospital survival compared with ECMO alone (OR = 1.58, 95% CI = 1.26–1.98, P < 0.0001). However, there were no significant differences in the duration of ECMO (MD = 0.36, 95% CI = −0.12–0.84, P = 0.14), duration of ICU stay (MD = −1.95, 95% CI = −4.05–0.15, P = 0.07), incidence of infection/sepsis (OR = 1.0, 95% CI = 0.58–1.72, P = 1.0), or bleeding (OR = 1.28, 95% CI = 0.48–3.45, P = 0.62) between the two groups of patients with CS. Conclusion ECMO combined with IABP can improve in-hospital survival more effectively than ECMO alone in patients with CS.
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Affiliation(s)
- Ping Zeng
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Chaojun Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jing Chen
- Hubei Key Laboratory of Cardiology, Department of Cardiology, Cardiovascular Research Institute, Renmin Hospital, Wuhan University, Wuhan, China
| | - Zhixing Fan
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Wanyin Cai
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Yifan Huang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Zujin Xiang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jun Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jing Zhang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
| | - Jian Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital, Yichang, China
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26
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Jin X, Wang Y. Case Report: Osmotic Demyelination Syndrome After Transcatheter Aortic Valve Replacement: Case Report and Review of Current Literature. Front Med (Lausanne) 2022; 9:915981. [PMID: 35795632 PMCID: PMC9251175 DOI: 10.3389/fmed.2022.915981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background Osmotic demyelination syndrome (ODS) has a low incidence but is a life-threatening neurological disorder whose common cause is rapid overcorrection of chronic hyponatremia. Transcatheter aortic valve replacement (TAVR) is a new and important therapy for patients with aortic valve stenosis. In this article, we discuss the case of a 64-year-old woman who developed ODS after TAVR and provide a literature review. Case Presentation A 64-year-old female patient was admitted to the hospital with chest tightness, shortness of breath, and fatigue for 2 months, with worsening of symptoms for 3 days prior to presentation. Auscultation revealed crackles in the lung fields, and systolic murmurs could be easily heard in the aortic area. Echocardiography showed severe aortic stenosis. Chest X-ray showed pulmonary oedema. Laboratory examinations showed that her serum sodium was 135 mmol/L. The patient received a diuretic to relieve her symptoms but showed little benefit. Her symptoms worsened, and her blood pressure dropped. Then, she underwent emergency TAVR under extracorporeal membrane oxygenation (ECMO) support. After the operation, her urine output increased markedly, and serum sodium increased sharply from 140 to 172 mmol/L. An MRI scan showed multiple lesions in the pons suggestive of ODS. Conclusion To date, this is the first reported case of a patient who developed ODS after receiving TAVR. In current clinical practice, diuretics are often used in aortic stenosis patients because of pulmonary oedema. After a patient receives TAVR, kidney perfusion pressure quickly returns to normal, and with the residual effect of a high-dose diuretic, balances of fluid volume and electrolyte levels in this phase are quite fragile and must be carefully managed. If a patient has neurological symptoms/signs during this phase, ODS should be considered, and MRI might be necessary.
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27
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Impact of the inspiratory oxygen fraction on the cardiac output during jugulo-femoral venoarterial extracorporeal membrane oxygenation in the rat. BMC Cardiovasc Disord 2022; 22:174. [PMID: 35428203 PMCID: PMC9013166 DOI: 10.1186/s12872-022-02613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Venoarterial extracorporeal membrane oxygenation (V-A ECMO) with femoral access has gained wide acceptance in the treatment of critically ill patients. Since the patient´s cardiac output (CO) can compete with the retrograde aortic ECMO-flow, the aim of this study was to examine the impact of the inspiratory oxygen fraction on the cardiac function during V-A ECMO therapy.
Methods
Eighteen male Lewis rats (350–400 g) received V-A ECMO therapy. The inspiratory oxygen fraction on the ventilator was randomly set to 0.5 (group A), 0.21 (group B), or 0 in order to simulate apnea (group C), respectively. Each group consisted of six animals. Arterial blood pressure, central venous saturation (ScvO2), CO, stroke volume, left ventricular ejection fraction (LVEF), end diastolic volume, and pressure were measured. Cardiac injury was determined by analyzing the amount of lactate dehydrogenase (LDH).
Results
During anoxic ventilation the systolic, mean and diastolic arterial pressure, CO, stroke volume, LVEF and ScvO2 were significantly impaired compared to group A and B. The course of LDH values revealed no significant differences between the groups.
Conclusion
Anoxic ventilation during V-A ECMO with femoral cannulation leads to cardiogenic shock in rats. Therefore, awake V-A ECMO patients might be at risk for hypoxia-induced complications.
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Takaoka Y, Hamatani Y, Shibata T, Oishi S, Utsunomiya A, Kawai F, Komiyama N, Mizuno A. Quality indicators of palliative care for cardiovascular intensive care. J Intensive Care 2022; 10:15. [PMID: 35287745 PMCID: PMC8922808 DOI: 10.1186/s40560-022-00607-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/01/2022] [Indexed: 01/11/2023] Open
Abstract
Healthcare providers working for cardiovascular intensive care often face challenges and they play an essential role in palliative care and end-of-life care because of the high mortality rates in the cardiac intensive care unit. Unfortunately, there are several barriers to integrating palliative care, cardiovascular care, and intensive care. The main reasons are as follows: cardiovascular disease-specific trajectories differ from cancer, there is uncertainty associated with treatments and diagnoses, aggressive treatments are necessary for symptom relief, and there is ethical dilemma regarding withholding and withdrawal of life-sustaining therapy. Quality indicators that can iterate the minimum requirements of each medical discipline could be used to overcome these barriers and effectively practice palliative care in cardiovascular intensive care. Unfortunately, there are no specific quality indicators for palliative care in cardiovascular intensive care. A few indicators and their domains are useful for understanding current palliative care in cardiovascular intensive care. Among them, several domains, such as symptom palliation, patient- and family-centered decision-making, continuity of care, and support for health care providers that are particularly important in cardiovascular intensive care. Historically, the motivation for using quality indicators is to summarize mechanisms for external accountability and verification, and formative mechanisms for quality improvement. Practically, when using quality indicators, it is necessary to check structural indicators in each healthcare service line, screen palliative care at the first visit, and integrate palliative care teams with other professionals. Finally, we would like to state that quality indicators in cardiovascular intensive care could be useful as an educational tool for practicing palliative care, understanding the minimum requirements, and as a basic structure for future discussions.
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Affiliation(s)
- Yoshimitsu Takaoka
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Shogo Oishi
- Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan
| | - Akemi Utsunomiya
- Department of Critical Care Nursing, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Fujimi Kawai
- St. Luke's International University Library, Tokyo, Japan
| | - Nobuyuki Komiyama
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan. .,Penn Medicine Nudge Unit, University of Pennsylvania Philadelphia, Philadelphia, PA, USA. .,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Zheng A, Zhang W, Li C, Guo Z, Li C, Zhang C, Yao J, Zhang Z, Li J, Zhao S, Zhou L. The heparinase-linked differential time method allows detection of heparin potency in whole blood with high sensitivity and dynamic range. Biosens Bioelectron 2022; 198:113856. [PMID: 34871836 DOI: 10.1016/j.bios.2021.113856] [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: 10/19/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/18/2022]
Abstract
Anticoagulation therapy with heparin is an effective treatment against thrombosis. Heparin tends to cause spontaneous bleeding and requires regular monitoring during therapy. Most high-sensitivity heparin sensors have focused on the concentration detection in clarified buffer solution. However, the pharmacodynamics of heparin vary depending on individual patient or disease, while potency detection with high sensitivity and dynamic range outperforms concentration detection in clinical diagnosis. In this study, a novel heparinase-linked differential time (HLDT) method was established with a two-zone of Graphene modified Carbon (GR-C) sensor, which was utilized to evaluate heparin potency in whole blood. It was based on electrochemical measurement of clotting time shifting associated with presence or absence of heparinase. Heparinase inhibits the anticoagulant ability of heparin by forming a heparin-antithrombin-thrombin complex during coagulation. And the intensity and peak time of electrochemical current were associated with thrombin activity and clotting on the electrode. The results demonstrated that the sensor had high selectivity for heparin potency in 10 μL of whole blood with a detection limit of 0.1 U/mL, and the linear detection range was 0.1-5 U/mL. The coefficient of variation (CV) of the peak time was less than 5%, and linear correlation between the GR-C sensor and the TEG-5000 instrument was 0.987. Thus, the HLDT method has better clinical application due to its good repeatability, high sensitivity and wide range in heparin potency evaluation.
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Affiliation(s)
- Anran Zheng
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Wei Zhang
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Chao Li
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Ji Hua Laboratory, Foshan, 528000, China
| | - Zhen Guo
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Suzhou CASENS Co., Ltd, Suzhou, 215163, China; Ji Hua Laboratory, Foshan, 528000, China
| | - Chuanyu Li
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Suzhou CASENS Co., Ltd, Suzhou, 215163, China
| | - Changsong Zhang
- Department of Laboratory Medicine, The Affiliated Suzhou Science and Technology Town Hospital, Nanjing Medical University, Suzhou 215153, Jiangsu Province, China
| | - Jia Yao
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Zhiqi Zhang
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Jinze Li
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Shasha Zhao
- CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China
| | - Lianqun Zhou
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, China; CAS Key Lab of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163, China; Ji Hua Laboratory, Foshan, 528000, China.
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30
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Zhang Q, Han Y, Sun S, Zhang C, Liu H, Wang B, Wei S. Mortality in cardiogenic shock patients receiving mechanical circulatory support: a network meta-analysis. BMC Cardiovasc Disord 2022; 22:48. [PMID: 35152887 PMCID: PMC8842943 DOI: 10.1186/s12872-022-02493-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Mechanical circulatory support (MCS) devices are widely used for cardiogenic shock (CS). This network meta-analysis aims to evaluate which MCS strategy offers advantages. Methods A systemic search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was performed. Studies included double-blind, randomized controlled, and observational trials, with 30-day follow-ups. Paired independent researchers conducted the screening, data extraction, quality assessment, and consistency and heterogeneity assessment. Results We included 39 studies (1 report). No significant difference in 30-day mortality was noted between venoarterial extracorporeal membrane oxygenation (VA-ECMO) and VA-ECMO plus Impella, Impella, and medical therapy. According to the surface under the cumulative ranking curve, the optimal ranking of the interventions was surgical venting plus VA-ECMO, medical therapy, VA-ECMO plus Impella, intra-aortic balloon pump (IABP), Impella, Tandem Heart, VA-ECMO, and Impella plus IABP. Regarding in-hospital mortality and 30-day mortality, the forest plot showed low heterogeneity. The results of the node-splitting approach showed that direct and indirect comparisons had a relatively high consistency. Conclusions IABP more effectively reduce the incidence of 30-day mortality compared with VA-ECMO and Impella for the treatment of CS. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02493-0.
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Saku K, Yokota S, Nishikawa T, Kinugawa K. Interventional heart failure therapy: A new concept fighting against heart failure. J Cardiol 2021; 80:101-109. [PMID: 34924236 DOI: 10.1016/j.jjcc.2021.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
Heart failure is a progressive disease that is associated with repeated exacerbations and hospitalizations. The rapid increase in the number of heart failure patients is a global health problem known as the 'heart failure pandemic'. To control the pandemic, multifaceted approaches are essential, ranging from prevention of onset to long-term disease management. Especially in patients with moderate to severe heart failure (stages C and D), surgical and catheter-based interventions are prerequisites for saving lives, preserving cardiac function, improving quality of life (QOL), and prognosis. In addition, various new medical technologies for these interventions have been clinically applied and have been shown to be effective against symptoms and improve the QOL and prognosis of patients with heart failure. Furthermore, the concept of interventional heart failure (IHF) therapy, which considers heart recovery and prevention of worsening of heart failure via multidisciplinary treatment using surgical, catheter interventions, and mechanical circulatory support devices, has been proposed worldwide. This review discusses the importance of IHF therapy in heart failure management, recent changes in interventional technologies and strategies for patients with heart failure, and worldwide education attempts for IHF specialists.
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Affiliation(s)
- Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan.
| | - Shohei Yokota
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Takuya Nishikawa
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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32
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Reid TD, Kratzke IM, Dayal D, Raff L, Serrano P, Kumar A, Zendel A, Herdman V, Gallaher J, Carlson R, Charles AG, Desai CS. The role of extracorporeal membrane oxygenation in adult liver transplant patients: A qualitative systematic review of literature. Artif Organs 2021; 46:578-596. [PMID: 34816462 DOI: 10.1111/aor.14120] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A paucity of evidence exists regarding risks and benefits of extracorporeal membrane oxygenation (ECMO) in adult liver transplantation. METHODS This was a systematic review conducted from January 1, 2000 to April 24, 2020 of adult liver transplant recipients (pre- or post-transplant) and donors who underwent Veno-arterial or Veno-venous ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS Forty-one articles were identified that fit criteria. A total of 183 donors were placed on ECMO, with recipient complication profiles and mortality that mirrored rates from standard criteria donors. Sixty-one recipients were placed on ECMO intraoperatively or postoperatively. Most patients experienced at least one complication with infections as the most common cause and minimal complications specifically related to ECMO use. Multisystem organ failure (MSOF) and infections were more common among liver recipients who died compared to those who survived. Overall mortality at 90 days was 45.9%. Causes of death were most commonly MSOF and infections. CONCLUSIONS ECMO use in adult liver transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO parallel that of recipients from standard criteria donors, and morbidity and mortality of recipients placed on ECMO are similar to other ECMO populations.
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Affiliation(s)
- Trista D Reid
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ian M Kratzke
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diana Dayal
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Raff
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Pablo Serrano
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aman Kumar
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alex Zendel
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Victoria Herdman
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jared Gallaher
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rebecca Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony G Charles
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chirag S Desai
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Acquired tracheomalacia due to aortic aneurysm managed with venopulmonary extracorporeal membrane oxygenation for perioperative support. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:737-740. [PMID: 34754999 PMCID: PMC8564725 DOI: 10.1016/j.jvscit.2021.09.004] [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: 06/11/2021] [Accepted: 09/04/2021] [Indexed: 12/02/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has diverse applications. In the present report, we have described a case of tracheomalacia from a thoracic aortic aneurysm causing respiratory failure. Total arch replacement with reverse frozen elephant trunk grafting was performed. Perioperative ECMO support was accomplished with venopulmonary artery ECMO. This strategy allowed for preoperative oxygenation support, venous drainage during cardiopulmonary bypass, and postoperative support without cannula exchanges. Our patient required ECMO support for 12 days postoperatively. We have illustrated a unique case of acquired tracheomalacia but also an ECMO cannulation strategy allowing for preoperative oxygenation, seamless transition to cardiopulmonary bypass, and postoperative support.
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34
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Cole SP, Martinez-Acero N, Peterson A, Von Homeyer P, Gebhardt B, Nicoara A. Imaging for Temporary Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2021; 36:2114-2131. [PMID: 34740543 DOI: 10.1053/j.jvca.2021.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Abstract
Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.
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Affiliation(s)
- Sheela Pai Cole
- Clinical Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Natalia Martinez-Acero
- Associate Physician, Cardiac Anesthesiology and Critical Care, Kaiser Permanente, Santa Clara, CA.
| | - Ashley Peterson
- Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Peter Von Homeyer
- Associate Professor, Department of Anesthesiology, University of Washington, Seattle, WA 98195.
| | | | - Alina Nicoara
- Associate Professor, Department of Anesthesiology, Duke University, Raleigh, NC 27708.
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35
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Potere B, Boulos R, Awad H, Taylor A, Kneuertz PJ, Cline M, Meyers L, Essandoh M, Henn M, Dalton R. The Role of Extracorporeal Membrane Oxygenation in the Anesthetic Management of Superior Vena Cava Syndrome: Is it Time to Use a Scoring System? J Cardiothorac Vasc Anesth 2021; 36:1777-1787. [PMID: 34531109 DOI: 10.1053/j.jvca.2021.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Bethany Potere
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Racha Boulos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Ashley Taylor
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Peter J Kneuertz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Cline
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lori Meyers
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Matthew Henn
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ryan Dalton
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Diagnostic yield of routine daily blood culture in patients on veno-arterial extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:241. [PMID: 34238367 PMCID: PMC8264470 DOI: 10.1186/s13054-021-03658-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Bloodstream infections (BSIs) are frequent on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Performing routine blood cultures (BCs) may identify early paucisymptomatic BSIs. We investigated the contribution of systematic daily BCs to detect BSIs on V-A ECMO. METHODS This was a retrospective study including all adult patients requiring V-A ECMO and surviving more than 24 h. Our protocol included routine daily BCs, from V-A ECMO insertion up to 5 days after withdrawal; other BCs were performed on-demand. RESULTS On the 150 V-A ECMO included, 2146 BCs were performed (1162 routine and 984 on-demand BCs); 190 (9%) were positive, including 68 contaminants. Fifty-one (4%) routine BCs revealed BSIs; meanwhile, 71 (7%) on-demand BCs revealed BSIs (p = 0.005). Performing routine BCs was negatively associated with BSIs diagnosis (OR 0.55, 95% CI [0.38; 0.81], p = 0.002). However, 16 (31%) BSIs diagnosed by routine BCs would have been missed by on-demand BCs. Independent variables for BSIs diagnosis after routine BCs were: V-A ECMO for cardiac graft failure (OR 2.43, 95% CI [1.20; 4.92], p = 0.013) and sampling with on-going antimicrobial therapy (OR 2.15, 95% CI [1.08; 4.27], p = 0.029) or renal replacement therapy (OR 2.05, 95% CI [1.10; 3.81], p = 0.008). Without these three conditions, only two BSIs diagnosed with routine BCs would have been missed by on-demand BCs sampling. CONCLUSIONS Although routine daily BCs are less effective than on-demand BCs and expose to contamination and inappropriate antimicrobial therapy, a policy restricted to on-demand BCs would omit a significant proportion of BSIs. This argues for a tailored approach to routine daily BCs on V-A ECMO, based on risk factors for positivity.
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37
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de Roux Q, Provenchere S, Longrois D, de Tymowski C. Coronary artery stent migration in aorta. Anaesth Crit Care Pain Med 2021; 40:100893. [PMID: 34058429 DOI: 10.1016/j.accpm.2021.100893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Quentin de Roux
- Department of Anaesthesiology and Surgical Intensive Care Unit, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, France; U955-IMRB, Equipe 03 « Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT) » Inserm, Univ. Paris Est Créteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), France
| | - Sophie Provenchere
- Department of Anaesthesiology and Surgical Intensive Care Unit, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, France
| | - Dan Longrois
- Department of Anaesthesiology and Surgical Intensive Care Unit, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, France; Université de Paris, Paris, France
| | - Christian de Tymowski
- Department of Anaesthesiology and Surgical Intensive Care Unit, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, France; Université de Paris, Paris, France; INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France.
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38
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Alba AC, Foroutan F, Buchan TA, Alvarez J, Kinsella A, Clark K, Zhu A, Lau K, McGuinty C, Aleksova N, Francis T, Stanimirovic A, Vishram-Nielsen J, Malik A, Ross HJ, Fan E, Rac VE, Rao V, Billia F. Mortality in patients with cardiogenic shock supported with VA ECMO: A systematic review and meta-analysis evaluating the impact of etiology on 29,289 patients. J Heart Lung Transplant 2021; 40:260-268. [DOI: 10.1016/j.healun.2021.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/06/2021] [Accepted: 01/14/2021] [Indexed: 01/08/2023] Open
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Luo JC, Su Y, Dong LL, Hou JY, Li X, Zhang Y, Ma GG, Zheng JL, Hao GW, Wang H, Zhang YJ, Luo Z, Tu GW. Trendelenburg maneuver predicts fluid responsiveness in patients on veno-arterial extracorporeal membrane oxygenation. Ann Intensive Care 2021; 11:16. [PMID: 33496906 PMCID: PMC7838230 DOI: 10.1186/s13613-021-00811-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Evaluation of fluid responsiveness during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is crucial. The aim of this study was to investigate whether changes in left ventricular outflow tract velocity-time integral (ΔVTI), induced by a Trendelenburg maneuver, could predict fluid responsiveness during VA-ECMO. METHODS This prospective study was conducted in patients with VA-ECMO support. The protocol included four sequential steps: (1) baseline-1, a supine position with a 15° upward bed angulation; (2) Trendelenburg maneuver, 15° downward bed angulation; (3) baseline-2, the same position as baseline-1, and (4) fluid challenge, administration of 500 mL gelatin over 15 min without postural change. Hemodynamic parameters were recorded at each step. Fluid responsiveness was defined as ΔVTI of 15% or more, after volume expansion. RESULTS From June 2018 to December 2019, 22 patients with VA-ECMO were included, and a total of 39 measurements were performed. Of these, 22 measurements (56%) met fluid responsiveness. The R2 of the linear regression was 0.76, between ΔVTIs induced by Trendelenburg maneuver and the fluid challenge. The area under the receiver operating characteristic curve of ΔVTI induced by Trendelenburg maneuver to predict fluid responsiveness was 0.93 [95% confidence interval (CI) 0.81-0.98], with a sensitivity of 82% (95% CI 60-95%), and specificity of 88% (95% CI 64-99%), at a best threshold of 10% (95% CI 6-12%). CONCLUSIONS Changes in VTI induced by the Trendelenburg maneuver could effectively predict fluid responsiveness in VA-ECMO patients. Trial registration ClinicalTrials.gov, NCT03553459 (the TEMPLE study). Registered on May 30, 2018.
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Affiliation(s)
- Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Li Dong
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China.
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
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Sawada K, Kawakami S, Murata S, Nishimura K, Tahara Y, Hosoda H, Nakashima T, Kataoka Y, Asaumi Y, Noguchi T, Sugimachi M, Fujita T, Kobayashi J, Yasuda S. Predicting Parameters for Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock. ESC Heart Fail 2020; 8:471-480. [PMID: 33264500 PMCID: PMC7835592 DOI: 10.1002/ehf2.13097] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/24/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022] Open
Abstract
Aims Percutaneous veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is utilized for patients with cardiogenic shock or cardiac arrest. However, the procedure protocol for weaning from VA‐ECMO has not been well established. The present study aimed to determine the usefulness of echocardiographic and pulmonary artery catheter parameters for predicting successful weaning from VA‐ECMO in patients with refractory cardiogenic shock. Methods and results We retrospectively studied 50 patients who were hospitalized and supported by VA‐ECMO for >48 h between January 2013 and March 2017. Patients successfully weaned from VA‐ECMO without reintroduction of VA‐ECMO or left ventricular assist device implantation were defined as 30 day survivors. Echocardiographic and pulmonary artery catheter parameters were evaluated when ECMO flow was limited to a maximum of 1.5–2.0 L/min. Twenty‐four patients were successfully weaned from VA‐ECMO, whereas 26 were not. Fractional shortening, corrected left ventricular ejection time (LVETc, defined as LVET divided by the square root of heart rate), left ventricular outflow tract velocity time integral, and LVETc divided by pulmonary artery wedge pressure (PAWP) were significantly larger in the 30 day survivor groups. Multivariable analysis revealed LVETc∕PAWP as a significant independent predictor of successful weaning (LVETc∕PAWP, odds ratio 0.82, 95% confidence interval 0.71–0.94, P = 0.005). Receiver operating characteristic curve analysis revealed 15.9 as the optimal LVETc∕PAWP for predicting successful weaning (area under the curve 0.82). Conclusions The present findings indicate that LVETc∕PAWP is a potential predictor of successful weaning from VA‐ECMO.
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Affiliation(s)
- Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shunsuke Murata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hayato Hosoda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Delmas C, Aissaoui N, Meneveau N, Bouvaist H, Rousseau H, Puymirat E, Sapoval M, Flecher E, Meyer G, Sanchez O, Del Giudice C, Roubille F, Bonello L. Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: A position paper from the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology. Arch Cardiovasc Dis 2020; 113:749-759. [PMID: 32978090 DOI: 10.1016/j.acvd.2020.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Inserm UMR 1048, Institute of Metabolic and Cardiovascular Diseases (I2MC), 31432 Toulouse, France
| | - Nadia Aissaoui
- Critical Care Unit, Penn State Heart and Vascular Institute (HVI), Hershey Medical Center (HMC) and Penn State University, 17033 PA, USA; Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen George Pompidou, AP-HP, 75015 Paris, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, 25000 Besancon, France
| | - Helene Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Hervé Rousseau
- Department of Radiology, Hôpital Rangueil 1, CHU de Toulouse, 31059 Toulouse, France
| | - Etienne Puymirat
- Intensive Cardiac Care Unit, Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Marc Sapoval
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Inserm UMR 1099, 35000 Rennes, France
| | - Guy Meyer
- Department of Pneumology, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris and CIC 1418, 75015 Paris, France
| | - Olivier Sanchez
- Department of Pulmonology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Inserm UMRS 1140, Université de Paris, 75270 Paris, France
| | - Costantino Del Giudice
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - François Roubille
- Department of Cardiology, CHU de Montpellier, Université de Montpellier, Inserm, CNRS, 34295 Montpellier, France
| | - Laurent Bonello
- Intensive Care Unit, Department of Cardiology, Hôpital Nord, AP-HM, Aix-Marseille Université, 13015 Marseille; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13000 Marseille, France; INSERM 1263, 1260, Centre for Cardiovascular and Nutrition Research (C2VN), INRA, 13385 Marseille, France.
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Avoidance of circulatory collapse by preoperative percutaneous drainage of tumor contents for a giant mediastinal mature cystic teratoma. Gen Thorac Cardiovasc Surg 2020; 69:401-404. [PMID: 32889680 DOI: 10.1007/s11748-020-01480-6] [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: 06/04/2020] [Accepted: 08/29/2020] [Indexed: 10/23/2022]
Abstract
Giant mediastinal tumors may cause fatal respiratory failure or circulatory collapse at the time of induction of general anesthesia and sometimes require extracorporeal life support. However, it is unclear whether preoperative percutaneous drainage of tumor contents for a giant mediastinal cystic teratoma reduces these risks. We report a case of a giant mediastinal cystic teratoma in which general anesthesia could be safely induced without extracorporeal life support by preoperative percutaneous drainage that reduced most of the tumor volume under local anesthesia. A 41-year-old woman diagnosed with a ruptured giant mediastinal teratoma required urgent surgery. To avoid circulatory collapse, preoperative percutaneous drainage of the tumor contents was performed, which successfully evacuated most of the tumor volume. General anesthesia was induced without any problem, and mediastinal tumorectomy was performed. We argue that it is worth attempting percutaneous drainage of tumor contents before cannulation of extracorporeal life support.
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Ju MH, Lim MH, Lee SY, Lee CH, Je HG. Early experience of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients with cardiogenic shock. Perfusion 2020; 36:401-406. [DOI: 10.1177/0267659120941328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Pump-controlled retrograde trial off has recently been introduced as an effective method for weaning from veno-arterial extracorporeal membrane oxygenation in pediatric patients. However, studies on pump-controlled retrograde trial off in adults are still lacking. Thus, this study aimed to examine the outcomes of pump-controlled retrograde trial off for weaning from veno-arterial extracorporeal membrane oxygenation in adult patients. Methods: Between January 2018 and July 2019, 87 consecutive adult patients underwent veno-arterial extracorporeal membrane oxygenation support, of whom 47 (54.0%) underwent pump-controlled retrograde trial off for weaning from extracorporeal membrane oxygenation and were enrolled in this study. The pump-controlled retrograde trial off results, extracorporeal membrane oxygenation reapplication rate, and clinical outcomes were analyzed. Results: Of the 47 patients, 38 (80.9%) were weaned from veno-arterial extracorporeal membrane oxygenation on the first attempt of pump-controlled retrograde trial off, 5 (10.6%) on the second attempt, and 4 (8.5%) on the third attempt. Three patients were converted to venovenous extracorporeal membrane oxygenation by desaturation but had stable blood pressure during pump-controlled retrograde trial off. No extracorporeal membrane oxygenation reapplication was performed within 3 days after removal, and two patients underwent veno-arterial extracorporeal membrane oxygenation during follow-up. No complications associated with pump-controlled retrograde trial off occurred during the weaning process, including thromboembolic events. Five in-hospital deaths (10.6%) occurred after weaning from extracorporeal membrane oxygenation. Conclusion: Pump-controlled retrograde trial off is an effective method to safely wean from veno-arterial extracorporeal membrane oxygenation in adult patients. It is simple and can be easily implemented without additional invasive procedures and may help prevent deterioration of the cardiovascular system after weaning from veno-arterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Min Ho Ju
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Mi Hee Lim
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo Yong Lee
- Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chee-Hoon Lee
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Hicks A, Velazco JF, Gohar S, Seliem A, Hall SA, Michel JB. Advanced heart failure with reduced ejection fraction. Proc AMIA Symp 2020; 33:350-356. [PMID: 32675952 PMCID: PMC7340451 DOI: 10.1080/08998280.2020.1765663] [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: 11/18/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022] Open
Abstract
Patients suffering advanced heart failure with reduced ejection fraction (HFrEF) account for a large portion of patients admitted to hospitals worldwide. Mortality and 30-day readmission rates for HFrEF are now a focus of value-based payment models, making management of this disease a priority for hospitals, physicians, and payers alike. Angiotensin-converting enzyme inhibitors have been the cornerstone of therapy for decades. However, with treatment, the prognosis for patients with advanced HFrEF remains poor. Fortunately, advances in medical therapy and mechanical support offer some patients improvement in both survival and quality of life. We review advances in short- and long-term mechanical support and explore changes to organ allocation for cardiac transplantation. In addition, we provide a guide to facilitate appropriate referral to an advanced heart failure team.
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Affiliation(s)
- Albert Hicks
- Division of Cardiology, Baylor Scott and White Medical Center – TempleTempleTexas
| | - Jorge F. Velazco
- Division of Pulmonary and Critical Care Medicine, Baylor Scott and White Medical Center – TempleTempleTexas
| | - Salman Gohar
- Division of Cardiology, Baylor Scott and White Medical Center – TempleTempleTexas
| | - Ahmed Seliem
- Baylor Scott & White Advanced Heart Failure Clinic, Baylor University Medical CenterDallasTexas
| | - Shelley A. Hall
- Baylor Scott & White Advanced Heart Failure Clinic, Baylor University Medical CenterDallasTexas
| | - Jeffrey B. Michel
- Division of Cardiology, Baylor Scott and White Medical Center – TempleTempleTexas
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Piechura LM, Coppolino A, Mody GN, Rinewalt DE, Keshk M, Ogawa M, Seethala R, Bohula EA, Morrow DA, Singh SK, Mallidi HR, Keller SP. Left ventricle unloading strategies in ECMO: A single-center experience. J Card Surg 2020; 35:1514-1524. [PMID: 32485030 PMCID: PMC7357854 DOI: 10.1111/jocs.14644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. MATERIALS & METHODS We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra-aortic balloon pump (IABP, n = 16), analyzing survival and ECMO-related complications. RESULTS Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). DISCUSSION Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.
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Affiliation(s)
- Laura M. Piechura
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Antonio Coppolino
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Gita N. Mody
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dan E. Rinewalt
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mohammed Keshk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mitsugu Ogawa
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Raghu Seethala
- Department of Emergency Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Erin A. Bohula
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David A. Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Hari R. Mallidi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
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Renaudier M, de Roux Q, Bougouin W, Boccara J, Dubost B, Attias A, Fiore A, de'Angelis N, Folliguet T, Mulé S, Amiot A, Langeron O, Mongardon N. Acute mesenteric ischaemia in refractory shock on veno-arterial extracorporeal membrane oxygenation. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:62–70. [PMID: 33609105 DOI: 10.1177/2048872620915655] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/08/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome. METHODS In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy. RESULTS One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02). CONCLUSIONS Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO.
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Affiliation(s)
- Marie Renaudier
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Quentin de Roux
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France.,U955-IMRB, Equipe 03 'Pharmacologie et technologies pour les maladies cardiovasculaires (PROTECT)' Inserm, Univ Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), France
| | - Wulfran Bougouin
- Réanimation polyvalente, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, France.,Paris Sudden Death Expertise Centre, Paris Cardiovascular Research Centre (PARCC), France.,AfterROSC Research Group, France
| | - Johanna Boccara
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Baptiste Dubost
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Arié Attias
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Antonio Fiore
- Service de chirurgie cardiaque, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Nicola de'Angelis
- Service de chirurgie digestive, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France.,Univ Paris Est Creteil, Faculté de Santé, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France.,Univ Paris Est Creteil, Faculté de Santé, France
| | - Sébastien Mulé
- Univ Paris Est Creteil, Faculté de Santé, France.,Service d'imagerie médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Aurélien Amiot
- Univ Paris Est Creteil, Faculté de Santé, France.,Service de gastro-entérologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France
| | - Olivier Langeron
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France.,Univ Paris Est Creteil, Faculté de Santé, France.,Département infection et épidémiologie, Institut Pasteur, Unité d'histopathologie et des modèles animaux, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale polyvalente, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, France.,U955-IMRB, Equipe 03 'Pharmacologie et technologies pour les maladies cardiovasculaires (PROTECT)' Inserm, Univ Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), France.,AfterROSC Research Group, France.,Univ Paris Est Creteil, Faculté de Santé, France
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Burgos LM, Seoane L, Furmento JF, Costabel JP, Diez M, Vrancic M, Aissaoui N, Benzadón MN, Navia D. Effects of levosimendan on weaning and survival in adult cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation: systematic review and meta-analysis. Perfusion 2020; 35:484-491. [DOI: 10.1177/0267659120918473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Veno-arterial extracorporeal membrane oxygenation may be used to support patients with refractory cardiogenic shock. Many patients can be successfully weaned, the ability of some medications to facilitate weaning from veno-arterial extracorporeal membrane oxygenation were reported. To date, there are limited studies investigating the impact of levosimendan on veno-arterial extracorporeal membrane oxygenation weaning. The objective of this systematic review and meta-analysis was to assess the effects of levosimendan on successful weaning from veno-arterial extracorporeal membrane oxygenation and survival in adult patients with cardiogenic shock. Methods: We performed a systematic review and meta-analysis (PubMed, the Cochrane Library, and the International Clinical Trials Registry Platform published from the year 2000 onwards) investigating whether levosimendan offers advantages compared to standard therapy or placebo, in cardiogenic shock adult patients treated with veno-arterial extracorporeal membrane oxygenation. The primary outcome was veno-arterial extracorporeal membrane oxygenation successful weaning, whereas secondary outcome was all-cause mortality at the longest follow-up available. We pooled risk ratio and 95% confidence interval using fixed and random effects models according to the heterogeneity. Results: A total of five non-randomized clinical trials comprising 557 patients were included, 299 patients for levosimendan and 258 patients for control groups. The pooled prevalence of veno-arterial extracorporeal membrane oxygenation successful weaning was 61.4% (95% confidence interval 39.8-82.9%), and all-cause mortality was 36% (95% confidence interval 29.6-48.8%). There was a significant increase in veno-arterial extracorporeal membrane oxygenation successful weaning with levosimendan compared to the controls (risk ratio = 1.42 (95% confidence interval 1.12-1.8), p for effect = 0.004, I2 = 71%). A decrease risk of all-cause mortality in the levosimendan group was also observed, risk ratio = 0.62 (95% confidence interval 0.44-0.88), p for effect = 0.007, I2 = 36%. Conclusion: The use of levosimendan on adult patients with cardiogenic shock may facilitate the veno-arterial extracorporeal membrane oxygenation weaning and reduce all-cause mortality. Few articles of this topic are available, and prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of levosimendan in this setting.
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Affiliation(s)
- Lucrecia María Burgos
- Heart Failure, Pulmonary Hypertension and Transplant Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Leonardo Seoane
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Francisco Furmento
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Pablo Costabel
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Mirta Diez
- Heart Failure, Pulmonary Hypertension and Transplant Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Mariano Vrancic
- Cardiac Surgery Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Nadia Aissaoui
- Penn State Heart and Vascular Institute (HVI), Critical Care Unit, Penn State Health Milton S. Hershey Medical Center (HMC), The Pennsylvania State University, Paris, France
| | - Mariano Noel Benzadón
- Critical Care Cardiology Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Daniel Navia
- Cardiac Surgery Department, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
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48
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Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
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Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
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49
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Grajeda Silvestri ER, Pino JE, Donath E, Torres P, Chait R, Ghumman W. Impella to unload the left ventricle in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock: A systematic review and meta‐analysis. J Card Surg 2020; 35:1237-1242. [DOI: 10.1111/jocs.14560] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Edwin R. Grajeda Silvestri
- Internal Medicine/CardiologyUniversity of Miami/JFK Medical Center Palm Beach Regional GME Consortium Atlantis Florida
| | - Jesus E. Pino
- Internal Medicine/CardiologyUniversity of Miami/JFK Medical Center Palm Beach Regional GME Consortium Atlantis Florida
| | - Elie Donath
- Internal Medicine/CardiologyUniversity of Miami/JFK Medical Center Palm Beach Regional GME Consortium Atlantis Florida
| | - Pedro Torres
- Internal Medicine/CardiologyUniversity of Miami/JFK Medical Center Palm Beach Regional GME Consortium Atlantis Florida
| | - Robert Chait
- Internal Medicine/CardiologyUniversity of Miami/JFK Medical Center Palm Beach Regional GME Consortium Atlantis Florida
| | - Waqas Ghumman
- Internal Medicine/CardiologyUniversity of Miami/JFK Medical Center Palm Beach Regional GME Consortium Atlantis Florida
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50
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Rali AS, Chandler J, Sauer A, Solomon MA, Shah Z. Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU. J Intensive Care Med 2019; 36:290-303. [PMID: 31830842 DOI: 10.1177/0885066619894541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.
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Affiliation(s)
- Aniket S Rali
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Jonathan Chandler
- Department of Internal Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Andrew Sauer
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Michael A Solomon
- Critical Care Medicine, 2511National Institutes of Health Clinical Center, Bethesda, MD, USA.,Cardiology Branch, National Heart, Lung, and Blood Institute, 2511National Institutes of Health, Bethesda, MD, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
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