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Abrams D, Curtis JR, Prager KM, Garan AR, Hastie J, Brodie D. Ethical Considerations for Mechanical Support. Anesthesiol Clin 2019; 37:661-673. [PMID: 31677684 DOI: 10.1016/j.anclin.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal life support can support patients with severe forms of cardiac and respiratory failure. Uncertainty remains about its optimal use owing in large part to its resource-intensive nature and the high acuity illness in supported patients. Specific issues include the identification of patients most likely to benefit, the appropriate duration of support when prognosis is uncertain, and what to do when patients become dependent on extracorporeal life support but no longer have hope for recovery or transplantation. Careful deliberation of ethical principles and potential dilemmas should be made when considering the use of extracorporeal life support in advanced cardiopulmonary failure.
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Affiliation(s)
- Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8E, 101, New York, NY 10032, USA.
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, USA
| | - Kenneth M Prager
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 161 Ft. Washington Avenue, Room 307, New York, NY 10032, USA
| | - A Reshad Garan
- Division of Cardiology, Columbia University College of Physicians and Surgeons, 177 Ft. Washington Avenue, 5th Floor, Room 5-435, New York, NY 10032, USA
| | - Jonathan Hastie
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 5-505, New York, NY 10032, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8E, 101, New York, NY 10032, USA
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Extracorporeal Membrane Oxygenation Is First-Line Therapy for Acute Respiratory Distress Syndrome. Crit Care Med 2019; 45:2070-2073. [PMID: 29035914 DOI: 10.1097/ccm.0000000000002734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Dzierba AL, Abrams D, Muir J, Brodie D. Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support. Pharmacotherapy 2019; 39:355-368. [DOI: 10.1002/phar.2230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Amy L. Dzierba
- Department of Pharmacy NewYork‐Presbyterian Hospital New York New York
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care Columbia University College of Physicians and Surgeons/NewYork‐Presbyterian Hospital New York New York
| | - Justin Muir
- Department of Pharmacy NewYork‐Presbyterian Hospital New York New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Columbia University College of Physicians and Surgeons/NewYork‐Presbyterian Hospital New York New York
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Trahanas JM, Lynch WR, Bartlett RH. Extracorporeal Support for Chronic Obstructive Pulmonary Disease: A Bright Future. J Intensive Care Med 2016; 32:411-420. [PMID: 27509917 DOI: 10.1177/0885066616663119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the past the only option for the treatment of respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) was invasive mechanical ventilation. In recent decades, the potential for extracorporeal carbon dioxide (CO2) removal has been realized. We review the various types of extracorporeal CO2 removal, outline the optimal use of these therapies for aeCOPD, and make suggestions for future controlled trials. We also describe the advantages and requirements for an ideal long-term ambulatory CO2 removal system for palliation of COPD.
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Affiliation(s)
- John M Trahanas
- 1 Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA.,2 Department of Surgery, Section of General Surgery, Columbia University Medical Center, New York, NY, USA
| | - William R Lynch
- 1 Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA.,3 Department of Surgery, Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert H Bartlett
- 1 Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
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Lehle K, Philipp A, Zeman F, Lunz D, Lubnow M, Wendel HP, Göbölös L, Schmid C, Müller T. Technical-Induced Hemolysis in Patients with Respiratory Failure Supported with Veno-Venous ECMO - Prevalence and Risk Factors. PLoS One 2015; 10:e0143527. [PMID: 26606144 PMCID: PMC4659553 DOI: 10.1371/journal.pone.0143527] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/05/2015] [Indexed: 11/18/2022] Open
Abstract
The aim of the study was to explore the prevalence and risk factors for technical-induced hemolysis in adults supported with veno-venous extracorporeal membrane oxygenation (vvECMO) and to analyze the effect of hemolytic episodes on outcome. This was a retrospective, single-center study that included 318 adult patients (Regensburg ECMO Registry, 2009–2014) with acute respiratory failure treated with different modern miniaturized ECMO systems. Free plasma hemoglobin (fHb) was used as indicator for hemolysis. Throughout a cumulative support duration of 4,142 days on ECMO only 1.7% of the fHb levels were above a critical value of 500 mg/l. A grave rise in fHb indicated pumphead thrombosis (n = 8), while acute oxygenator thrombosis (n = 15) did not affect fHb. Replacement of the pumphead normalized fHb within two days. Neither pump or cannula type nor duration on the first system was associated with hemolysis. Multiple trauma, need for kidney replacement therapy, increased daily red blood cell transfusion requirements, and high blood flow (3.0–4.5 L/min) through small-sized cannulas significantly resulted in augmented blood cell trauma. Survivors were characterized by lower peak levels of fHb [90 (60, 142) mg/l] in comparison to non-survivors [148 (91, 256) mg/l, p≤0.001]. In conclusion, marked hemolysis is not common in vvECMO with modern devices. Clinically obvious hemolysis often is caused by pumphead thrombosis. High flow velocity through small cannulas may also cause technical-induced hemolysis. In patients who developed lung failure due to trauma, fHb was elevated independantly of ECMO. In our cohort, the occurance of hemolysis was associated with increased mortality.
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Affiliation(s)
- Karla Lehle
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
- * E-mail:
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Peter Wendel
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Laszlo Göbölös
- Department of Cardiothoracic Surgery, Southampton University Hospital Trust, Southampton, United Kingdom
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
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Abrams D, Brodie D. Novel Uses of Extracorporeal Membrane Oxygenation in Adults. Clin Chest Med 2015; 36:373-84. [DOI: 10.1016/j.ccm.2015.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pujara D, Sandoval E, Simpson L, Mallidi HR, Singh SK. The State of the Art in Extracorporeal Membrane Oxygenation. Semin Thorac Cardiovasc Surg 2015; 27:17-23. [PMID: 26074105 DOI: 10.1053/j.semtcvs.2015.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2015] [Indexed: 11/11/2022]
Abstract
Extracorporeal membrane oxygenation has evolved in design, technology, patient selection, insertion techniques, adjunct devices, and management in the past 45 years since it began. Outcomes have improved and indications have expanded. It continues to be an expeditious, cost-effective tool for rapid resuscitation of patients with cardiorespiratory failure, whose outcomes without extracorporeal membrane oxygenation intervention are predominately fatal. However, results are still moderately satisfactory, and the ethical aspects of ongoing care need to be at the forefront of daily family discussions in patients for whom a bridge to transplant or definitive device is not possible.
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Affiliation(s)
- Deep Pujara
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas
| | - Elena Sandoval
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas
| | - Leo Simpson
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas
| | - Hari R Mallidi
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas
| | - Steve K Singh
- Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Texas.
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