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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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2
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Malas J, Chen Q, Shen T, Emerson D, Gunn T, Megna D, Catarino P, Nurok M, Bowdish M, Chikwe J, Cheng S, Ebinger J, Kumaresan A. Outcomes of Extremely Prolonged (> 50 d) Venovenous Extracorporeal Membrane Oxygenation Support. Crit Care Med 2023; 51:e140-e144. [PMID: 36927927 PMCID: PMC10272086 DOI: 10.1097/ccm.0000000000005860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVES There has been a sustained increase in the utilization of venovenous extracorporeal membrane oxygenation (ECMO) over the last decade, further exacerbated by the COVID-19 pandemic. We set out to describe our institutional experience with extremely prolonged (> 50 d) venovenous ECMO support for recovery or bridge to lung transplant candidacy in patients with acute respiratory failure. DESIGN Retrospective cohort study. SETTING A large tertiary urban care center. PATIENTS Patients 18 years or older receiving venovenous ECMO support for greater than 50 days, with initial cannulation between January 2018 and January 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred thirty patients were placed on venovenous ECMO during the study period. Of these, 12 received prolonged (> 50 d) venovenous ECMO support. Eleven patients (92%) suffered from adult respiratory distress syndrome (ARDS) secondary to COVID-19, while one patient with prior bilateral lung transplant suffered from ARDS secondary to bacterial pneumonia. The median age of patients was 39 years (interquartile range [IQR], 35-51 yr). The median duration of venovenous ECMO support was 94 days (IQR, 70-128 d), with a maximum of 180 days. Median time from intubation to cannulation was 5 days (IQR, 2-14 d). Nine patients (75%) were successfully mobilized while on venovenous ECMO support. Successful weaning of venovenous ECMO support occurred in eight patients (67%); 6 (50%) were bridged to lung transplantation and 2 (17%) were bridged to recovery. Of those successfully weaned, seven patients (88%) were discharged from the hospital. All seven patients discharged from the hospital were alive 6 months post-decannulation; 83% (5/6) with sufficient follow-up time were alive 1-year after decannulation. CONCLUSIONS Our experience suggests that extremely prolonged venovenous ECMO support to allow native lung recovery or optimization for lung transplantation may be a feasible strategy in select critically ill patients, further supporting the expanded utilization of venovenous ECMO for refractory respiratory failure.
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Affiliation(s)
- Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tao Shen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tyler Gunn
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Nurok
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Abirami Kumaresan
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
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3
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Levy L, Deri O, Huszti E, Nachum E, Ledot S, Shimoni N, Saute M, Sternik L, Kremer R, Kassif Y, Zeitlin N, Frogel J, Lambrikov I, Matskovski I, Chatterji S, Seluk L, Furie N, Shafran I, Mass R, Onn A, Raanani E, Grinberg A, Levy Y, Afek A, Kreiss Y, Kogan A. Timing of Lung Transplant Referral in Patients with Severe COVID-19 Lung Injury Supported by ECMO. J Clin Med 2023; 12:4041. [PMID: 37373734 DOI: 10.3390/jcm12124041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Severe respiratory failure caused by COVID-19 often requires mechanical ventilation, including extracorporeal membrane oxygenation (ECMO). In rare cases, lung transplantation (LTx) may be considered as a last resort. However, uncertainties remain about patient selection and optimal timing for referral and listing. This retrospective study analyzed patients with severe COVID-19 who were supported by veno-venous ECMO and listed for LTx between July 2020 and June 2022. Out of the 20 patients in the study population, four who underwent LTx were excluded. The clinical characteristics of the remaining 16 patients were compared, including nine who recovered and seven who died while awaiting LTx. The median duration from hospitalization to listing was 85.5 days, and the median duration on the waitlist was 25.5 days. Younger age was significantly associated with a higher likelihood of recovery without LTx after a median of 59 days on ECMO, compared to those who died at a median of 99 days. In patients with severe COVID-19-induced lung damage supported by ECMO, referral to LTx should be delayed for 8-10 weeks after ECMO initiation, particularly for younger patients who have a higher probability of spontaneous recovery and may not require LTx.
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Affiliation(s)
- Liran Levy
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ofir Deri
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON M5G 1X6, Canada
| | - Eyal Nachum
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Stephane Ledot
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Nir Shimoni
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Milton Saute
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Thoracic Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Leonid Sternik
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ran Kremer
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Thoracic Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yigal Kassif
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Nona Zeitlin
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Thoracic Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Jonathan Frogel
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ilya Lambrikov
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ilia Matskovski
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Sumit Chatterji
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Seluk
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Nadav Furie
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Inbal Shafran
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ronen Mass
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Amir Onn
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Institute of Pulmonary Medicine, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ehud Raanani
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Amir Grinberg
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yuval Levy
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Arnon Afek
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yitshak Kreiss
- General Management, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Alexander Kogan
- The Sheba Lung Transplant Program, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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Mannem H, Aversa M, Keller T, Kapnadak SG. The Lung Transplant Candidate, Indications, Timing, and Selection Criteria. Clin Chest Med 2023; 44:15-33. [PMID: 36774161 DOI: 10.1016/j.ccm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation can be lifesaving for patients with advanced lung disease. Demographics are evolving with recipients now sicker but determining candidacy remains predicated on one's underlying lung disease prognosis, along with the likelihood of posttransplant success. Determining optimal timing can be challenging, and most programs favor initiating the process early and proactively to allow time for patient education, informed decision-making, and preparation. A comprehensive, multidisciplinary evaluation is used to elucidate disease progrnosis and identify risk factors for poor posttransplant outcomes. Candidacy criteria vary significantly by center, and close communication between referring and transplant providers is necessary to improve access to transplant and outcomes.
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Affiliation(s)
- Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia School of Medicine, PO Box 800546, Clinical Department Wing, 1 Hospital Drive, Charlottesville, VA 22908, USA
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON M5S 3H2, Canada
| | - Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA.
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Outcomes of Venovenous Extracorporeal Membrane Oxygenation in Viral Acute Respiratory Distress Syndrome. ASAIO J 2022; 68:1399-1406. [PMID: 36326705 DOI: 10.1097/mat.0000000000001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Our study assessed the relationship between the duration of venovenous extracorporeal membrane oxygenation (V-V ECMO) and patient outcomes. We studied patients undergoing V-V ECMO support for acute respiratory distress syndrome (ARDS) between 2009 and 2017 who were reported to the Extracorporeal Life Support Organization registry. We evaluated survival, major bleeding, renal failure, pulmonary complications, mechanical complications, neurologic complications, infection, and duration of V-V ECMO support. Multivariable regression modeling assessed risk factors for adverse events. Of the 4,636 patients studied, the mean support duration was 12.2 ± 13.7 days. There was a progressive increase in survival after the initiation of V-VECMO, peaking at a survival rate of 73% at 10 days of support. However, a single-day increase in V-V ECMO duration was associated with increased bleeding events (odds ratio [OR] 1.038; 95% confidence interval [CI]: 1.029-1.047; p < 0.0001), renal failure (OR 1.018; 95% CI: 1.010-1.027; p < 0.0001), mechanical complications (OR 1.065; 95% CI: 1.053-1.076; p < 0.0001), pulmonary complications (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001), and infection (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001). V-V ECMO progressively increases survival for ARDS over the first 10 days of support. Thereafter, rising complications associated with prolonged durations of support result in a progressive decline in survival.
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Schmandt M, Putensen C, Stiehl T, Wagenpfeil J, Schewe JC, Ehrentraut SF. Be Patient: Prolonged Extracorporeal Membrane Oxygenation Support Including Full System Switch With Favorable Outcome. J Med Cases 2022; 13:483-490. [PMID: 36407859 PMCID: PMC9635769 DOI: 10.14740/jmc3979] [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: 07/03/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023] Open
Abstract
Despite tremendous advances in treatment, acute respiratory distress syndrome (ARDS) remains a disease with high mortality (42-48%). Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is often used as a last treatment option, which poses complex problems for the treatment team, especially with prolonged ECMO support. We report an interesting case of a 40-year-old female patient who developed influenza pneumonia leading to ARDS and subsequently requiring ECMO. Due to severe clotting complications, a prolonged ECMO run time with numerous filter changes was required. After a total of 56 days of ECMO therapy, the patient was successfully weaned. Fortunately, further in the course of treatment, complete recovery with restitutio ad integrum was achieved. A distinguishing feature of this case report is the description of a complete ECMO system change and the concurrent use of two ECMO systems for the same patient. Additionally, we provide data on the patient's current health-related quality of life as measured using the World Health Organization Disability Assessment Schedule 2.0.
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Affiliation(s)
- Mathias Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany,Corresponding Author: Mathias Schmandt, Department of Anesthesiology and Intensive Care Medicine, Venusberg-Campus 1, 53127 Bonn, Germany.
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tatjana Stiehl
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Julia Wagenpfeil
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Stefan Felix Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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7
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Son J, Shin C. Indications for Lung Transplantation and Patient Selection. J Chest Surg 2022; 55:255-264. [PMID: 35924530 PMCID: PMC9358156 DOI: 10.5090/jcs.22.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Globally, thousands of patients undergo lung transplantation owing to end-stage lung disease each year. As lung transplantation evolves, recommendations and indications are constantly being updated. In 2021, the International Society for Heart and Lung Transplantation published a new consensus document for selecting candidates for lung transplantation. However, it is still difficult to determine appropriate candidates for lung transplantation among patients with complex medical conditions and various diseases. Therefore, it is necessary to analyze each patient’s overall situation and medical condition from various perspectives, and ongoing efforts to optimize the analysis will be necessary. The purpose of this study is to review the extant literature and discuss recent updates.
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Affiliation(s)
- Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Changwon Shin
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
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Lüsebrink E, Zimmer S, Schrage B, Dabboura S, Majunke N, Scherer C, Aksoy A, Krogmann A, Hoffmann S, Szczanowicz L, Binzenhöfer L, Peterss S, Kühn C, Hagl C, Massberg S, Schäfer A, Thiele H, Westermann D, Orban M. Intracranial haemorrhage in adult patients on venoarterial extracorporeal membrane oxygenation. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:303-311. [PMID: 35213724 DOI: 10.1093/ehjacc/zuac018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/15/2022] [Accepted: 01/30/2022] [Indexed: 06/14/2023]
Abstract
AIMS Intracranial haemorrhage (ICH) is one of the most serious complications of adult patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and is associated with increased morbidity and mortality. However, the prevalence and risk factors of ICH in this cohort are still insufficiently understood. We hypothesized that a considerable proportion of patients undergoing VA-ECMO support suffer from ICH and that specific risk factors are associated with the occurrence of ICH. Therefore, the purpose of this study was to further investigate the prevalence and associated mortality as well as to identify risk factors for ICH in VA-ECMO patients. METHODS AND RESULTS We conducted a retrospective multicentre study including adult patients (≥18 years) treated with VA-ECMO in cardiac intensive care units (ICUs) at five German clinical sites between January 2016 and March 2020, excluding patients with ICH upon admission. Differences in baseline characteristics and clinical outcome between VA-ECMO patients with and without ICH were analysed and risk factors for ICH were identified. Among the 598 patients included, 70/598 (12%) developed ICH during VA-ECMO treatment. In-hospital mortality in patients with ICH was 57/70 (81%) and 1-month mortality 60/70 (86%), compared to 332/528 (63%) (P = 0.002) and 340/528 (64%) (P < 0.001), respectively, in patients without ICH. Intracranial haemorrhage was positively associated with diabetes mellitus [odds ratio (OR) 2, 95% confidence interval (CI) 1.11-3.56; P = 0.020] and lactate (per mmol/L) (OR 1.06, 95% CI 1.01-1.11; P = 0.020), and negatively associated with platelet count (per 100 G/L) (OR 0.32, 95% CI 0.15-0.59; P = 0.001) and fibrinogen (per 100 mg/dL) (OR 0.64, 95% CI 0.49-0.83; P < 0.001). CONCLUSION Intracranial haemorrhage was associated with a significantly higher mortality rate. Diabetes mellitus and lactate were positively, platelet count, and fibrinogen level negatively associated with the occurrence of ICH. Thus, platelet count and fibrinogen level were revealed as potentially modifiable, independent risk factors for ICH. The findings address an area with limited data, provide information about risk factors and the epidemiology of ICH, and may be a starting point for further investigations to develop effective strategies to prevent and treat ICH.
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Affiliation(s)
- Enzo Lüsebrink
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Munich Heart Alliance, Munich, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Salim Dabboura
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nicolas Majunke
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Leipzig, Germany
| | - Clemens Scherer
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Munich Heart Alliance, Munich, Germany
| | - Adem Aksoy
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Alexander Krogmann
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Sabine Hoffmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilians Universität München, Munich, Germany
| | - Lukasz Szczanowicz
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Leipzig, Germany
| | - Leonhard Binzenhöfer
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Munich Heart Alliance, Munich, Germany
| | - Sven Peterss
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Munich, Germany
| | - Christian Kühn
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medizinischen Hochschule Hannover, Hannover, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Munich, Germany
| | - Steffen Massberg
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Munich Heart Alliance, Munich, Germany
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Leipzig, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Martin Orban
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Munich Heart Alliance, Munich, Germany
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9
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Shah A, Pasrija C, Kronfli A, Essien EO, Zhou Y, Brigante F, Bittle G, Menaker J, Herr D, Mazzeffi MA, Deatrick KB, Kon ZN. A Comparison of Anticoagulation Strategies in Veno-venous Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:738-743. [PMID: 34437329 DOI: 10.1097/mat.0000000000001560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Bleeding remains a major source of morbidity associated with veno-venous extracorporeal membrane oxygenation (VV-ECMO). Moreover, there remains significant controversy, and a paucity of data regarding the ideal anticoagulation strategy for VV-ECMO patients. All patients undergoing isolated, peripheral VV-ECMO between January 2009 and December 2014 at our institution were retrospectively reviewed. Patients (n = 123) were stratified into one of three sequential eras of anticoagulation strategies: activated clotting time (ACT: 160-180 seconds, n = 53), high-partial thromboplastin time (H-PTT: 60-80 seconds, n = 25), and low-PTT (L-PTT: 45-55 seconds, n = 25) with high-flow (>4 L/min). Pre-ECMO APACHE II scores, SOFA scores, and Murray scores were not significantly different between the groups. Patients in the L-PTT group required less red blood cell units on ECMO than the ACT or H-PTT group (2.1 vs. 1.3 vs. 0.9; p < 0.001) and patients in the H-PTT and L-PTT group required less fresh frozen plasma than the ACT group (0.33 vs. 0 vs. 0; p = 0.006). Overall, major bleeding events were significantly lower in the L-PTT group than in the ACT and H-PTT groups. There was no difference in thrombotic events. In this single-institution experience, a L-PTT, high-flow strategy on VV-ECMO was associated with fewer bleeding and no difference in thrombotic events than an ACT or H-PTT strategy.
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Affiliation(s)
- Aakash Shah
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Chetan Pasrija
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Anthony Kronfli
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eno-Obong Essien
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ya Zhou
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Francis Brigante
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Gregory Bittle
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Jay Menaker
- Shock Trauma Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Herr
- Shock Trauma Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Kristopher B Deatrick
- From the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, New York University Medical Center, New York, NY
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10
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Bermudez CA, Crespo MM. The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation. Transplantation 2022; 106:e198-e199. [PMID: 35135969 PMCID: PMC8942598 DOI: 10.1097/tp.0000000000004063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christian A Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
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11
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Argaw ST, Devlin PJ, Clark JA, Garza-Castillon R, Kurihara C, Bharat A. Fracture of dual lumen cannula leading to cerebrovascular accident in a patient supported with ECMO. J Artif Organs 2022; 25:279-282. [PMID: 35039962 PMCID: PMC8763437 DOI: 10.1007/s10047-021-01306-z] [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: 09/28/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022]
Abstract
Extended duration extracorporeal membrane oxygenation (ECMO), using dual-lumen cannulas, is being used with increased frequency to support patients, including those with COVID-19; both as a bridge to transplant and lung recovery. During such an extended duration of support, there are several factors that might lead to the attrition of the physical structure of the ECMO cannulas, predisposing them to the risk of fracture. Although rare, fracture of the ECMO cannula can be a potentially lethal event. Here, we present a case where fracture of a dual lumen cannula during veno-venous (VV) ECMO support resulted in a cerebrovascular accident. We discuss the potential contributing factors and suggest steps to mitigate the risks for such a complication.
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Affiliation(s)
- Salem T Argaw
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - Paul J Devlin
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - James A Clark
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - Rafael Garza-Castillon
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
| | - Chitaru Kurihara
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 650, Chicago, IL, 60611, USA.
| | - Ankit Bharat
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 650, Chicago, IL, 60611, USA. .,Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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12
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Leard LE, Holm AM, Valapour M, Glanville AR, Attawar S, Aversa M, Campos SV, Christon LM, Cypel M, Dellgren G, Hartwig MG, Kapnadak SG, Kolaitis NA, Kotloff RM, Patterson CM, Shlobin OA, Smith PJ, Solé A, Solomon M, Weill D, Wijsenbeek MS, Willemse BWM, Arcasoy SM, Ramos KJ. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 PMCID: PMC8979471 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 329] [Impact Index Per Article: 109.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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Affiliation(s)
| | | | | | | | - Sandeep Attawar
- Krishna Institute of Medical Sciences Institute for Heart and Lung Transplantation, Hyderabad, India
| | | | - Silvia V Campos
- Heart Institute (InCor) University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | | | - Göran Dellgren
- Sahlgrenska University Hospital and University of Gothenburg, Sweden
| | | | | | | | | | | | | | | | | | - Melinda Solomon
- Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - David Weill
- Weill Consulting Group, New Orleans, Louisiana
| | | | - Brigitte W M Willemse
- Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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13
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Kim DH, Cho WH, Son J, Lee SK, Yeo HJ. Catastrophic Mechanical Complications of Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:1000-1005. [PMID: 33528158 DOI: 10.1097/mat.0000000000001354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Technical advances in extracorporeal membrane oxygenation (ECMO) have increased the number of cases that maintain longer duration. Long-term use of ECMO results in ECMO-related complications. Anticipation of the life-threatening mechanical complications and their management are critical for safe ECMO. In this study, we analyzed the incidence, nature, and risk factors of life-threatening mechanical complications during ECMO support. Furthermore, we presented our bedside algorithms to manage catastrophic ECMO complications. Data from 549 patients who underwent ECMO between December 2008 and December 2018 were retrospectively analyzed. The incidence of all life-threatening mechanical complications was 4.0%. Accidental decannulation (1.3%) was most common, followed by abrupt falling circuit flows (1.1%), pump failure (1.1%), circuit rupture (0.4%), and air in circuit (0.2%). Most (90.9%) of life-threatening events required circuit and cannula change, while 9.1% required vein collapse relief procedure. There was no death related to the event; however, six (27.3%) died during ECMO due to the underlying disease for which ECMO was required, and three (13.6%) died after weaning from ECMO. Multivariate regression analysis showed that awake ECMO and long-term ECMO support were significantly associated with life-threatening mechanical complications (p < 0.01). Our algorithm safely managed catastrophic ECMO problems without event-related deaths.
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Affiliation(s)
- Do Hyung Kim
- From the Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital
| | - Woo Hyun Cho
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Joohyung Son
- From the Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital
| | - Sung Kwang Lee
- From the Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital
| | - Hye Ju Yeo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
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14
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Umei N, Ichiba S, Genda Y, Mase H, Sakamoto A. Hospital survival outcomes in acute respiratory distress syndrome patients receiving veno-venous extracorporeal membrane oxygenation for longer than 28 days: A retrospective study. Artif Organs 2021; 45:1533-1542. [PMID: 34398471 DOI: 10.1111/aor.14051] [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: 04/05/2021] [Revised: 07/27/2021] [Accepted: 08/07/2021] [Indexed: 11/30/2022]
Abstract
The successful use of prolonged (ie, >28 days) veno-venous extracorporeal membrane oxygenation (V-V ECMO) is being increasingly reported. However, limited data are available on its outcomes. This study investigated the outcomes of acute respiratory distress syndrome (ARDS) patients on prolonged ECMO support. We retrospectively evaluated 57 patients requiring V-V ECMO for ARDS between 2015 and 2020. The patients were divided into two groups according to ECMO duration: (a) ≤28 days group (n = 43, 75%) or (b) >28 days (n = 14, 25%) group. Clinical characteristics, complications, and outcomes between these two groups were statistically compared. There were no significant differences in demographics, comorbidity, ARDS etiology, and severity scores between the two groups. However, the mechanical ventilation period before ECMO initiation was significantly longer in the >28 days group than in the ≤28 days group (10.5 days vs. 1 day; P < .05). The incidence of positive bacterial blood culture results during ECMO was significantly higher in the >28 days group than in the ≤28 days group (43% vs. 9%; P < .05). Additionally, the hospital survival rate was significantly lower in the >28 days group than in the ≤28 days ECMO group (21% vs. 60%; P < .05). Prolonged ECMO was associated with worse hospital survival outcomes. Early initiation of ECMO along with meticulous care and appropriate treatment against infection during ECMO could improve the hospital survival of ARDS patients on prolonged ECMO support.
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Affiliation(s)
- Nao Umei
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.,Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Shingo Ichiba
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuki Genda
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Mase
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.,Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.,Department of Surgical Intensive Care Medicine, Nippon Medical School, Tokyo, Japan
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15
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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16
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Lepper PM, Barrett NA, Swol J, Lorusso R, Di Nardo M, Belliato M, Bělohlávek J, Broman LM. Perception of prolonged extracorporeal membrane oxygenation in Europe: an EuroELSO survey. Perfusion 2021; 35:81-85. [PMID: 32397893 DOI: 10.1177/0267659120909740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The substantial increase in the number of patients receiving extracorporeal membrane oxygenation over the last decade has led to an evolution of indications and an expansion into wider patient groups. One of the unanticipated benefits of the increase in extracorporeal membrane oxygenation has been a change in the understanding of the natural history of many respiratory diseases. Development in technology and materials, reduced extracorporeal membrane oxygenation-specific complications, and improvement of critical care, in general, have facilitated longer extracorporeal membrane oxygenation runs, and the definition of prolonged extracorporeal membrane oxygenation was recently expanded to continuous support for more than 28 days. This survey aimed to describe European ECMO centers' perception and arbitrary definition of prolonged extracorporeal membrane oxygenation, patient management, and futility. Of 94 center responses, 37% regarded 14-21 days, 30% 21-28 days, and 28% >28 days as prolonged treatment. Bridge to recovery (64%) or to transplantation (20%) was the most common causes. Awake, and ambulation while on extracorporeal membrane oxygenation was reported from 34% of the centers. In case of perceived futility, decision to withdraw was taken in 65% of the centers in agreement between profession and family and in 30% by profession only. One-fourth of the centers did not discontinue support. Large differences prevail among European ECMO centers concerning local perception and patient management in prolonged extracorporeal membrane oxygenation.
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Affiliation(s)
- Philipp M Lepper
- Klinik für Innere Medizin V, Universitätskliniken des Saarlandes, Universität des Saarlandes, Homburg, Germany
| | - Nicholas A Barrett
- Department of Critical Care and Severe Respiratory Failure Service, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jan Bělohlávek
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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17
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Rabie AA, Asiri A, Rajab M, Mufti HN, Alsherbiny M, Azzam MH, Abdelbary A, Zakhary B, Arabi Y, Alharthy A, Futaih M, Sobhy M, Alenazi I, Bafaqeeh F. Beyond Frontiers: Feasibility and Outcomes of Prolonged Veno-Venous Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome. ASAIO J 2021; 67:339-344. [PMID: 33627610 DOI: 10.1097/mat.0000000000001367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) use in acute respiratory failure is increasing. We aim to compare characteristics and outcomes of patients with prolonged (≥21 days) veno-venous (VV) ECMO runs (pECMO), to patients with short (<21 days) VV ECMO runs (sECMO). The observational retrospective single-center study compared patients who received VV ECMO from January 2018 to June 2019 at Prince Mohamed Bin Abdulaziz Center in Riyadh, Saudi Arabia. Forty-three patients were supported with VV ECMO during the study period, of whom 37 are included as six patients were still receiving ECMO at time of data collection: 24 sECMO and 13 pECMO patients. Baseline characteristics and comorbidities were similar except pECMO patients were older and had a lower P/F ratio (61 [58-68] vs. 71[58-85.5], p = 0.05). Survival to hospital discharge (69% vs. 83%, p = 0.32; pECMO vs. sECMO) and 90 day survival (62% vs. 75%, p = 0.413; pECMO vs. sECMO) were similar among groups. At 1 year follow-up, all patients were still alive and independently functioning except for one patient in the pECMO group who required a walking aid related to trauma. In this single-center study, patients requiring pECMO had similar short- and long-term survival to those requiring sECMO duration.
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Affiliation(s)
- Ahmed A Rabie
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ayed Asiri
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Mostafa Rajab
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Hani N Mufti
- Cardiac Surgery Department, King Faisal Cardiac Center, King Saud Bin Abdulaziz University for Health Sciences, MNGHA Jeddah, Saudi Arabia
| | - Medhat Alsherbiny
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Critical Care Department, King Abdullah Medical Complex, Ministry of Health, Jeddah, Saudi Arabia
| | | | - Bishoy Zakhary
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Yaseen Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Mohamed Futaih
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Mohamed Sobhy
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Ismael Alenazi
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Fahad Bafaqeeh
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
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18
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Dreier E, Malfertheiner MV, Dienemann T, Fisser C, Foltan M, Geismann F, Graf B, Lunz D, Maier LS, Müller T, Offner R, Peterhoff D, Philipp A, Salzberger B, Schmidt B, Sinner B, Lubnow M. ECMO in COVID-19-prolonged therapy needed? A retrospective analysis of outcome and prognostic factors. Perfusion 2021. [PMID: 33612020 DOI: 10.1177/0267659121995997]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy. METHODS A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed. RESULTS Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8-32.1) ml/cmH2O vs 18.7 (17.7-25.0) ml/cmH2O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16-23) days vs 5 (5-9) days, p = 0.002) and SOFA score was higher (12.0 (10.5-17.0) vs 10.0 (9.0-10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome. CONCLUSIONS VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.
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Affiliation(s)
- Esther Dreier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Thomas Dienemann
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Geismann
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Lars Siegfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Sinner
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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19
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Dreier E, Malfertheiner MV, Dienemann T, Fisser C, Foltan M, Geismann F, Graf B, Lunz D, Maier LS, Müller T, Offner R, Peterhoff D, Philipp A, Salzberger B, Schmidt B, Sinner B, Lubnow M. ECMO in COVID-19-prolonged therapy needed? A retrospective analysis of outcome and prognostic factors. Perfusion 2021; 36:582-591. [PMID: 33612020 PMCID: PMC8369905 DOI: 10.1177/0267659121995997] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: The role of venovenous extracorporeal membrane oxygenation (VV ECMO) in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) still remains unclear. Our aim was to investigate the clinical course and outcome of those patients and to identify factors associated with the need for prolonged ECMO therapy. Methods: A retrospective single-center study on patients with VV ECMO for COVID-19-associated ARDS was performed. Baseline characteristics, ventilatory and ECMO parameters, and laboratory and virological results were evaluated over time. Six months follow-up was assessed. Results: Eleven of 16 patients (68.8%) survived to 6 months follow-up with four patients requiring short-term (<28 days) and seven requiring prolonged (⩾28 days) ECMO support. Lung compliance before ECMO was higher in the prolonged than in the short-term group (28.1 (28.8–32.1) ml/cmH2O vs 18.7 (17.7–25.0) ml/cmH2O, p = 0.030). Mechanical ventilation before ECMO was longer (19 (16–23) days vs 5 (5–9) days, p = 0.002) and SOFA score was higher (12.0 (10.5–17.0) vs 10.0 (9.0–10.0), p = 0.002) in non-survivors compared to survivors. Low viral load during the first days on ECMO tended to indicate worse outcomes. Seroconversion against SARS-CoV-2 occurred in all patients, but did not affect outcome. Conclusions: VV ECMO support for COVID-19-induced ARDS is justified if initiated early and at an experienced ECMO center. Prolonged ECMO therapy might be required in those patients. Although no relevant predictive factors for the duration of ECMO support were found, the decision to stop therapy should not be made dependent of the length of ECMO treatment.
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Affiliation(s)
- Esther Dreier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Thomas Dienemann
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Geismann
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Graf
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Lars Siegfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Robert Offner
- Institute of Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Regensburg, Germany
| | - David Peterhoff
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department for Infection Control and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Schmidt
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Sinner
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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The Prolonged Use of VV ECMO Support in COVID-19: A Case Report. J Crit Care Med (Targu Mures) 2020; 6:224-230. [PMID: 33200093 PMCID: PMC7648436 DOI: 10.2478/jccm-2020-0034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 09/29/2020] [Indexed: 01/08/2023] Open
Abstract
COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery.
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21
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Abstract
Since the first successful case report in 1972, extracorporeal life support or extracorporeal membrane oxygenation (ECMO) has become a standard approach for severe respiratory failure unresponsive to other therapy. In the past, if there was no recovery by approximately 30 days or if right ventricular heart failure occurred, ECMO was discontinued and the patient died. More recently patients with severe lung disease have been maintained for months, as opposed to days, with eventual decannulation and recovery. We report the case of a child, 7 years old, with severe inhalational burn injury and rapid progression to multisystem organ failure. She was supported by ECMO with no lung function for almost 2 years. Central nervous system function remained normal and lung function recovered. This is the longest successful case of ECMO to date and prompts further discussion regarding "irreversible" lung injury.
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22
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Wadowski BJ, Bacchetta M, Kon ZN. Beware the Deus Ex Machina of COVID-19. Ann Thorac Surg 2020; 110:1787-1788. [PMID: 32871108 PMCID: PMC7455797 DOI: 10.1016/j.athoracsur.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Benjamin J Wadowski
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York; Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomechanical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York.
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23
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Masterson CH, Murphy EJ, Gonzalez H, Major I, McCarthy SD, O'Toole D, Laffey JG, Rowan NJ. Purified β-glucans from the Shiitake mushroom ameliorates antibiotic-resistant Klebsiella pneumoniae-induced pulmonary sepsis. Lett Appl Microbiol 2020; 71:405-412. [PMID: 32706908 DOI: 10.1111/lam.13358] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/26/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022]
Abstract
Bacterial infection remains the main cause of acute respiratory distress syndrome and is a leading cause of death and disability in critically ill patients. Here we report on the use of purified β-glucan (lentinan) extracts from Lentinus edodes (Shiitake) mushroom that can reduce infection by a multidrug-resistant clinical isolate of Klebsiella pneumoniae in a rodent pneumonia model, likely through immunomodulation. Adult male Sprague-Dawley rats were subjected to intra-tracheal administration of K. pneumoniae to induce pulmonary sepsis and randomized to three groups; vehicle control (Vehicle, n = 12), commercial lentinan (CL, n = 8) or in-house extracted lentinan (IHL, n = 8) were administered intravenously 1 h postinfection. Physiological parameters and blood gas analysis were measured, bacterial counts from bronchoalveolar-lavage (BAL) were determined, along with differential staining of white cells and measurement of protein concentration in BAL 48 h after pneumonia induction. Use of IHL extract significantly decreased BAL CFU counts. Both CL and IHL extractions reduced protein concentration in BAL. Use of IHL resulted in an improvement in physiological parameters compared to controls and CL. In conclusion, administration of lentinan to treat sepsis-induced lung injury appears safe and effective and may exert its effects in an immunomodulatory manner.
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Affiliation(s)
- C H Masterson
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - E J Murphy
- Bioscience Research Institute, Athlone Institute of Technology, Athlone, Ireland
| | - H Gonzalez
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - I Major
- Materials Research Institute, Athlone Institute of Technology, Athlone, Ireland
| | - S D McCarthy
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - D O'Toole
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - J G Laffey
- Lung Biology Group, National University of Ireland, Galway, Ireland.,Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
| | - N J Rowan
- Centre for Disinfection, Sterilisation and Biosecurity, Athlone Institute of Technology, Athlone, Ireland
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24
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Sheckley M, Calderon E, Patel BM, Sen A, Giorgakis E, Hewitt WR, Singer AL, Reddy KS, Moss AA, Mathur AK. Utilization of Veno-Arterial Extracorporeal Life Support for Acute Respiratory Distress Syndrome After Liver Transplant. EXP CLIN TRANSPLANT 2020; 20:616-620. [PMID: 32778014 DOI: 10.6002/ect.2020.0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this report, we present a case of successful long-term salvage of a patient with transfusion-related acute lung injury associated with acute respiratory distress syndrome immediately after a liver transplant. The patient was a 29-year-old man with end-stage liver disease due to sclerosing cholangitis who underwent liver transplant. After organ reperfusion, there was evidence of liver congestion, acidosis, coagulopathy, and acute kidney injury. He received 61 units of blood products. Continuous renal replacement therapy was initiated intraoperatively. On arrival to the intensive care unit, the patient was on high-dose pressors, and the patient developed respiratory failure and was immediately placed on veno-arterial extracorporeal membrane oxygenation via open femoral exposure. The patient presented with severe coagulopathy and early allograft dysfunction; therefore, no systemic heparin was administered and no thrombotic events occurred. He required extracorporeal membrane oxygenation support until posttransplant day 4, when resolution of the respiratory and cardiac dysfunction was noted. At 2 years after liver transplant, the patient has normal liver function, normal cognitive function, and stage V chronic kidney disease. We conclude that extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with cardiorespiratory failure after liver transplant.
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Affiliation(s)
- Marwan Sheckley
- From the Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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25
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Byrnes D, Masterson CH, Artigas A, Laffey JG. Mesenchymal Stem/Stromal Cells Therapy for Sepsis and Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2020; 42:20-39. [PMID: 32767301 DOI: 10.1055/s-0040-1713422] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Sepsis and acute respiratory distress syndrome (ARDS) constitute devastating conditions with high morbidity and mortality. Sepsis results from abnormal host immune response, with evidence for both pro- and anti-inflammatory activation present from the earliest phases. The "proinflammatory" response predominates initially causing host injury, with later-phase sepsis characterized by immune cell hypofunction and opportunistic superinfection. ARDS is characterized by inflammation and disruption of the alveolar-capillary membrane leading to injury and lung dysfunction. Sepsis is the most common cause of ARDS. Approximately 20% of deaths worldwide in 2017 were due to sepsis, while ARDS occurs in over 10% of all intensive care unit patients and results in a mortality of 30 to 45%. Given the fact that sepsis and ARDS share some-but not all-underlying pathophysiologic injury mechanisms, the lack of specific therapies, and their frequent coexistence in the critically ill, it makes sense to consider therapies for both conditions together. In this article, we will focus on the therapeutic potential of mesenchymal stem/stromal cells (MSCs). MSCs are available from several tissues, including bone marrow, umbilical cord, and adipose tissue. Allogeneic administration is feasible, an important advantage for acute conditions like sepsis or ARDS. They possess diverse mechanisms of action of relevance to sepsis and ARDS, including direct and indirect antibacterial actions, potent effects on the innate and adaptive response, and pro-reparative effects. MSCs can be preactivated thereby potentiating their effects, while the use of their extracellular vesicles can avoid whole cell administration. While early-phase clinical trials suggest safety, considerable challenges exist in moving forward to phase III efficacy studies, and to implementation as a therapy should they prove effective.
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Affiliation(s)
- Declan Byrnes
- Department of Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute (REMEDI), CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Claire H Masterson
- Department of Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute (REMEDI), CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Antonio Artigas
- Critical Care Center, Corporació Sanitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - John G Laffey
- Department of Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute (REMEDI), CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia, SAOLTA University Health Group, Galway University Hospitals, Galway, Ireland
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26
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Abstract
Circulating venous blood outside the body, through an artificial lung (membrane oxygenator), and returning oxygenated blood to the patient is extracorporeal gas exchange. Oxygen and carbon dioxide exchange in a membrane lung is controlled by regulating blood flow, blood composition, and device design. With this control, lung function can be replaced for weeks by artificial organs. © 2020 American Physiological Society. Compr Physiol 10:879-891, 2020.
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27
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Na SJ, Jeon K. Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome. Expert Rev Respir Med 2020; 14:511-519. [PMID: 32089016 DOI: 10.1080/17476348.2020.1734457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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28
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Ramanathan K. Ethical challenges of adult ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:303-308. [PMID: 33967451 DOI: 10.1007/s12055-020-00922-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 01/10/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) is expanding rapidly, and as more centres streamline their management policies, the bioethics literature on ECMO has been highlighting the ethical challenges of using an expensive, resource-intensive technology including its eligibility, duration of support, cost-effectiveness and societal repercussions. The absence of high-quality studies on long-term outcomes of ECMO survivors leads to multiple ethical problems involving patient autonomy, beneficence and clinical wisdom pertaining to its initiation, maintenance and termination. This article reviews some of the ethical challenges that affect decision-making during ECMO therapy and suggests an ethical framework that may help the treating team deal with such conundrums, when the patient does not recover despite being on ECMO.
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Affiliation(s)
- Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.,Bond University, Gold Coast, Australia
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29
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Spontaneous breathing in patients with severe acute respiratory distress syndrome receiving prolonged extracorporeal membrane oxygenation. BMC Pulm Med 2019; 19:237. [PMID: 31818300 PMCID: PMC6902615 DOI: 10.1186/s12890-019-1016-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 11/29/2019] [Indexed: 12/02/2022] Open
Abstract
Background The use of extracorporeal membrane oxygenation (ECMO) in awake, spontaneously breathing and non-intubated patients (awake ECMO) may be a novel therapeutic strategy for severe acute respiratory distress syndrome (ARDS) patients. The purpose of this study is to assess the feasibility and safety of awake ECMO in severe ARDS patients receiving prolonged ECMO (> 14 days). Methods We describe our experience with 12 consecutive severe ARDS patients (age, 39.1 ± 16.4 years) supported with awake ECMO to wait for native lung recovery during prolonged ECMO treatment from July 2013 to January 2018. Outcomes are reported including the hospital mortality, ECMO-related complications and physiological data on weaning from invasive ventilation. Results The patients received median 26.0 (15.5, 64.8) days of total ECMO duration in the cohort. The longest ECMO support duration was 121 days. Awake ECMO and extubation was implemented after median 10.2(5.0, 42.9) days of ECMO. Awake ECMO was not associated with increased morbidity. The total invasive ventilation duration, lengths of stay in the ICU and hospital in the cohort were 14.0(12.0, 37.3) days, 33.0(22.3, 56.5) days and 46.5(27.3, 84.8) days, respectively. The hospital mortality rate was 33.3% (4/12) in the cohort. Survivors had more stable respiratory rate and heart rate after extubation when compared to the non-survivors. Conclusions With carefully selected patients, awake ECMO is a feasible and safe strategy for severe pulmonary ARDS patients receiving prolonged ECMO support to wait for native lung recovery.
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Al-Fares A, Fan E, Husain S, Di Nardo M, Cypel M, Keshavjee S, Herridge MS, Del Sorbo L. Veno-venous extracorporeal life support for blastomycosis-associated acute respiratory distress syndrome. Perfusion 2019; 34:660-670. [PMID: 31027465 DOI: 10.1177/0267659119844391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Blastomyces is a dimorphic fungus endemic to regions of North America, which can lead to pneumonia and fatal severe acute respiratory diseases syndrome in up to 89% of patients. Extracorporeal life support can provide adequate oxygenation while allowing the lungs to rest and heal, which might be an ideal therapy in this patient group, although long-term clinical and radiological outcomes are not known. CLINICAL FEATURES We report on five consecutive patients admitted to Toronto General Hospital intensive care unit between January 2012 and September 2016, with progressive respiratory failure requiring veno-venous extracorporeal life support within 24-96 hours following mechanical ventilation. Ultra-lung protective mechanical ventilation was achieved within 24 hours. Recovery was the initial goal in all patients. Extracorporeal life support was provided for a prolonged period (up to 49 days), and four patients were successfully discharged from the intensive care unit. Long-term radiological assessment in three patients showed major improvement within 2 years of follow-up with some persistent disease-related changes (bronchiectasis, fibrosis, and cystic changes). In two patients, long-term functional and neuropsychological outcomes showed similar limitations to what is seen in acute respiratory distress syndrome patients who are not supported with extracorporeal life support and in acute respiratory distress syndrome patients without blastomycosis, but worse pulmonary function outcomes in the form of obstructive and restrictive changes that correlated with the radiological imaging. CONCLUSION Veno-venous extracorporeal life support can effectively provide prolonged support for patients with blastomycosis-associated acute respiratory distress syndrome that is safe and associated with favorable long-term outcomes.
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Affiliation(s)
- Abdulrahman Al-Fares
- Adult Critical Care Medicine Fellowship Program, University of Toronto, Toronto, ON, Canada.,Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait.,Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
| | - Shahid Husain
- Division of Infectious Diseases and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Matteo Di Nardo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Pediatric Critical Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Marcelo Cypel
- Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.,Division of Thoracic Surgery and Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.,Division of Thoracic Surgery and Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
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31
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Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure: How Long Is Too Long? ASAIO J 2019; 65:192-196. [DOI: 10.1097/mat.0000000000000791] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Na SJ, Jung JS, Hong SB, Cho WH, Lee SM, Cho YJ, Park S, Koo SM, Park SY, Chang Y, Kang BJ, Kim JH, Oh JY, Park SH, Yoo JW, Sim YS, Jeon K. Clinical outcomes of patients receiving prolonged extracorporeal membrane oxygenation for respiratory support. Ther Adv Respir Dis 2019; 13:1753466619848941. [PMID: 31090503 PMCID: PMC6535699 DOI: 10.1177/1753466619848941] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/05/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There are limited data regarding prolonged extracorporeal membrane oxygenation (ECMO) support, despite increase in ECMO use and duration in patients with respiratory failure. The objective of this study was to investigate the outcomes of severe acute respiratory failure patients supported with prolonged ECMO for more than 28 days. METHODS Between January 2012 and December 2015, all consecutive adult patients with severe acute respiratory failure who underwent ECMO for respiratory support at 16 tertiary or university-affiliated hospitals in South Korea were enrolled retrospectively. The patients were divided into two groups: short-term group defined as ECMO for ⩽28 days and long-term group defined as ECMO for more than 28 days. In-hospital and 6-month mortalities were compared between the two groups. RESULTS A total of 487 patients received ECMO support for acute respiratory failure during the study period, and the median support duration was 8 days (4-20 days). Of these patients, 411 (84.4%) received ECMO support for ⩽28 days (short-term group), and 76 (15.6%) received support for more than 28 days (long-term group). The proportion of acute exacerbation of interstitial lung disease as a cause of respiratory failure was higher in the long-term group than in the short-term group (22.4% versus 7.5%, p < 0.001), and the duration of mechanical ventilation before ECMO was longer (4 days versus 1 day, p < 0.001). The hospital mortality rate (60.8% versus 69.7%, p = 0.141) and the 6-month mortality rate (66.2% versus 74.0%, p = 0.196) were not different between the two groups. ECMO support longer than 28 days was not associated with hospital mortality in univariable and multivariable analyses. CONCLUSIONS Short- and long-term survival rates among patients receiving ECMO support for more than 28 days for severe acute respiratory failure were not worse than those among patients receiving ECMO for 28 days or less.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Hyun Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Gyeongsangnam-do, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sunghoon Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, Republic of Korea
| | - So-My Koo
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Seung Yong Park
- Department of Internal Medicine, Chonbuk National University Hospital, Jeollabuk-do, Republic of Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Byung Ju Kang
- Division of Pulmonology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jung-Hyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, CHA Bundang Medical Center, Gyeonggi-do, Republic of Korea
| | - Jin Young Oh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Jung-Wan Yoo
- Department of Internal Medicine, College of Medicine, Gyeongsang National University Hospital, Gyeonsangnam-do, Republic of Korea
| | - Yun Su Sim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
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Bartlett RH. Late recovery from total lung injury after ECMO support. EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2018. [DOI: 10.1016/j.ejccm.2018.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ali ASA, Yosri M, Abouelwafa M, Saad M, Zaki K, Mashhour S, Salah H, Mohsen T, Abozeid A, Khaled M, Abdelbary A, Abdelfattah A. One hundred forty six days on extracorporeal membrane oxygenation (ECMO): Our longest ECMO run. THE EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2018. [DOI: 10.1016/j.ejccm.2018.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Wang ZY, Li T, Wang CT, Xu L, Gao XJ. Assessment of 1-year Outcomes in Survivors of Severe Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation or Mechanical Ventilation: A Prospective Observational Study. Chin Med J (Engl) 2018; 130:1161-1168. [PMID: 28485315 PMCID: PMC5443021 DOI: 10.4103/0366-6999.205847] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Little is known about the long-term outcomes of severe acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO). This study aimed to investigate the 1-year outcomes of these patients or patients receiving mechanical ventilation (MV) and compare their health-related quality of life (HRQoL) to the general population. Methods: Severe ARDS survivors admitted to two ICUs in China between January 2012 and January 2014 were enrolled. Of the severe ARDS survivors enrolled, 1-year postdischarge, HRQoL assessment using the Short-Form 36 (SF-36) and EuroQol questionnaire dimensions, 6-min walking distance, chest computed tomography scan, pulmonary function, and arterial blood gas analysis were compared for ARDS patients with or without ECMO. Results: ARDS patients receiving ECMO had a significantly higher Acute Physiology and Chronic Health Evaluation II score (30.3 ± 6.7 vs. 26.5 ± 7.3, P = 0.036), lung injury score (3.3 ± 0.4 vs. 2.8 ± 0.5, P = 0.000), Sequential Organ Failure Assessment score (10.8 ± 3.5 vs. 7.9 ± 3.1, P = 0.000), lower PaO2/FiO2 ratio ([mmHg, 1 mmHg = 0.133 kPa], 68.3 ± 16.1 vs. 84.8 ± 16.5, P = 0.000), and increased extrapulmonary organ failure (2 [1, 3] vs. 1 [1, 1], P = 0.025) compared with patients not receiving ECMO. ECMO and non-ECMO survivors showed similar pulmonary function, morphological abnormalities, resting arterial blood gas values, and 6-min walking distance. Mild pulmonary dysfunction and abnormal morphology were observed in a few survivors. In addition, ECMO and non-ECMO survivors showed a similar quality of life. ECMO survivors showed lower SF-36 physical functioning and role-physical domain scores (minimum clinically significant difference at least 5 points), and non-ECMO survivors had similar outcome. Conclusions: One-year posthospital discharge, severe ARDS survivors receiving ECMO or MV demonstrated comparable outcomes. Compared with the general population, ARDS survivors showed reduced HRQoL. Pulmonary function and lung morphology revealed sufficient recovery with minor lung impairment.
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Affiliation(s)
- Zhi-Yong Wang
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Artificial Cells Key Laboratory of Tianjin, Tianjin 300170, China
| | - Tong Li
- Heart Center, Tianjin Third Central Hospital, Tianjin 300170, China
| | - Chun-Ting Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital, Jinan, Shandong 250021, China
| | - Lei Xu
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Artificial Cells Key Laboratory of Tianjin, Tianjin 300170, China
| | - Xin-Jing Gao
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Artificial Cells Key Laboratory of Tianjin, Tianjin 300170, China
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Takagaki M, Yamaguchi H, Mitsuyama S, Kadowaki T, Ando T. Successful management of prolonged venovenous extracorporeal membrane oxygenation in an octogenarian. J Artif Organs 2017; 20:377-380. [DOI: 10.1007/s10047-017-0999-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/25/2017] [Indexed: 01/31/2023]
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Cooper DK, Wijkstrom M, Hariharan S, Chan JL, Singh A, Horvath K, Mohiuddin M, Cimeno A, Barth RN, LaMattina JC, Pierson RN. Selection of Patients for Initial Clinical Trials of Solid Organ Xenotransplantation. Transplantation 2017; 101:1551-1558. [PMID: 27906824 PMCID: PMC5453852 DOI: 10.1097/tp.0000000000001582] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Several groups have reported extended survival of genetically engineered pig organs in nonhuman primates, varying from almost 10 months for life-supporting kidney grafts and more than 2 years for non-life-supporting heart grafts to less than 1 month for life-supporting liver and lung grafts. We have attempted to define groups of patients who may not have an option to wait for an allograft. These include kidney, heart, and lung candidates who are highly-allosensitized. In addition, some kidney candidates (who have previously lost at least 2 allografts from rapid recurrence of native kidney disease) have a high risk of further recurrence and will not be offered a repeat allotransplant. Patients with complex congenital heart disease, who may have undergone previous palliative surgical procedures, may be unsuitable for ventricular assist device implantation. Patients dying of fulminant hepatic failure, for whom no alternative therapy is available, may be candidates for a pig liver, even if only as a bridge until an allograft becomes available. When the results of pig organ xenotransplantation in nonhuman primates suggest a realistic potential for success of a pilot clinical trial, highly selected patients should be offered participation.
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Affiliation(s)
- David K.C. Cooper
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martin Wijkstrom
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Sundaram Hariharan
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Joshua L. Chan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Avneesh Singh
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Keith Horvath
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Muhammad Mohiuddin
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Arielle Cimeno
- Division of Transplantation Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD
| | - Rolf N. Barth
- Division of Transplantation Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD
| | - John C. LaMattina
- Division of Transplantation Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD
| | - Richard N. Pierson
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, Baltimore VAMC, Baltimore, MD, USA
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Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era: A systematic review. J Crit Care 2017; 41:64-71. [PMID: 28499130 DOI: 10.1016/j.jcrc.2017.04.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/06/2017] [Accepted: 04/24/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the hospital survival in patients with severe ARDS managed with ECMO and low tidal volume ventilation as compared to patients managed with low tidal volume ventilation alone. METHODS Electronic databases were searched for studies of at least 10 adult patients with severe ARDS comparing the use of ECMO with low tidal volume ventilation to mechanical ventilation with a low tidal volume alone. Only studies reporting hospital or ICU survival were included. All identified studies were assessed independently by two reviewers. RESULTS Of 1782 citations, 27 studies (n=1674) met inclusion criteria. Hospital survival for ECMO patients ranged from 33.3 to 86%, while survival with conventional therapy ranged from 36.3 to 71.2%. Five studies were identified with appropriate control groups allowing comparison, but due to the high degree of variability between studies (I2=63%), their results could not be pooled. Two of these studies demonstrated a significant difference, both favouring ECMO over conventional therapy. CONCLUSION Given the lack of studies with appropriate control groups, our confidence in a difference in outcome between the two therapies remains weak. Future studies on the use of ECMO for severe ARDS are needed to clarify the role of ECMO in this disease.
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Affiliation(s)
- Tasleem Raza
- Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatarwww.hamad.qa
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Squiers JJ, Lima B, DiMaio JM. Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence. J Thorac Cardiovasc Surg 2016; 152:20-32. [DOI: 10.1016/j.jtcvs.2016.02.067] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 01/30/2016] [Accepted: 02/28/2016] [Indexed: 12/15/2022]
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Luyt CE, Bréchot N, Demondion P, Jovanovic T, Hékimian G, Lebreton G, Nieszkowska A, Schmidt M, Trouillet JL, Leprince P, Chastre J, Combes A. Brain injury during venovenous extracorporeal membrane oxygenation. Intensive Care Med 2016; 42:897-907. [PMID: 27007107 DOI: 10.1007/s00134-016-4318-3] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/09/2016] [Indexed: 01/19/2023]
Abstract
PURPOSE The frequency of neurological events and their impact on patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) are unknown. We therefore study the epidemiology, risk factors, and impact of cerebral complications occurring in VV-ECMO patients. METHODS Observational study conducted in a tertiary referral center (2006-2012) on patients developing a neurological complication (ischemic stroke or intracranial bleeding) while on VV-ECMO versus those who did not, and a systematic review on this topic. RESULTS Among 135 consecutive patients who had received VV-ECMO, 18 (15 assessable) developed cerebral complications on ECMO: cerebral bleeding in 10 (7.5 %), ischemic stroke in 3 (2 %), or diffuse microbleeds in 2 (2 %), occurring after respective medians (IQR) of 3 (1-11), 21 (10-26), and 36 (8-63) days post-ECMO onset. Intracranial bleeding was independently associated with renal failure at intensive care unit admission and rapid PaCO2 decrease at ECMO initiation, but not with age, comorbidities, or hemostasis disorders. Seven (70 %) patients with intracranial bleeding and one (33 %) with ischemic stroke died versus 40 % of patients without neurological event. A systematic review found comparable intracranial bleeding rates (5 %). CONCLUSIONS Neurological events occurred frequently in patients on VV-ECMO. Intracranial bleeding, the most frequent, occurred early and was associated with higher mortality. Because it was independently associated with rapid hypercapnia decrease, the latter should be avoided at ECMO onset, but its exact role remains to be determined. These findings may have major implications for the care of patients requiring VV-ECMO.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Nicolas Bréchot
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pierre Demondion
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Tamara Jovanovic
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ania Nieszkowska
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Matthieu Schmidt
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jean-Louis Trouillet
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean Chastre
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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