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Ait Hssain A, Vahedian-Azimi A, Ibrahim AS, Hassan IF, Azoulay E, Darmon M. Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis. Crit Care 2024; 28:158. [PMID: 38730424 PMCID: PMC11088079 DOI: 10.1186/s13054-024-04946-8] [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: 03/26/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-analysis aim to assess the incidence and risk factors of NIs in adult. METHODS We searched PubMed, Scopus, Web of Science, and ProQuest databases up to 2022. The primary endpoint was incidence of NI. Secondary endpoints included time to infection, source of infection, ECMO duration, Intensive care and hospital length of stay (LOS), ECMO survival and overall survival. Incidence of NI was reported as pooled proportions and 95% confidence intervals (CIs), while dichotomous outcomes were presented as risk ratios (RR) as the effective index and 95% CIs using a random-effects model. RESULTS Among the 4,733 adult patients who received ECMO support in the 30 included studies, 1,249 ECMO-related NIs per 1000 ECMO-days was observed. The pooled incidence of NIs across 18 studies involving 3424 patients was 26% (95% CI 14-38%).Ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) were the most common NI sources. Infected patients had lower ECMO survival and overall survival rates compared to non-infected patients, with risk ratio values of 0.84 (95% CI 0.74-0.96, P = 0.01) and 0.80 (95% CI 0.71-0.90, P < 0.001), respectively. CONCLUSION Results showed that 16% and 20% lower of ECMO survival and overall survival in patients with NI than patients without NI, respectively. However, NI increased the risk of in-hospital mortality by 37% in infected patients compared with non-infected patients. In addition, this study identified the significant positive correlation between ECMO duration and ECMO-related NI.
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Affiliation(s)
- Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
- College of Health and Life Science, Hamad Bin Khalifa University, Doha, Qatar
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Sheykh Bahayi Street, Vanak Square, P.O. Box 19575-174, Tehran, Iran.
| | - Abdulsalam Saif Ibrahim
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Michael Darmon
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
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Zheng YR, Chen XH, Chen Q, Cao H. Metagenomic Next-generation Sequencing for Pathogen Identification in Bronchoalveolar Lavage Fluid From Neonates Receiving Extracorporeal Membrane Oxygenation. Pediatr Infect Dis J 2024; 43:371-377. [PMID: 38306604 DOI: 10.1097/inf.0000000000004250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
BACKGROUND Neonates on extracorporeal membrane oxygenation (ECMO) are at high risk of infection. Rapid and accurate identification of pathogens is essential to improve the prognosis of children on ECMO. Metagenome next-generation sequencing (mNGS) has been used in recent years to detect pathogenic bacteria, but evidence for its use in neonates on ECMO is lacking. METHODS This retrospective study was conducted using an electronic medical record system. We analyzed the results of mNGS and conventional microbiological tests (CMTs) in bronchoalveolar lavage fluid of neonates receiving ECMO support with pulmonary infections in our hospital from July 2021 to January 2023. RESULTS We screened 18 ECMO-supported neonates with pneumonia for inclusion in the study. The median age of the included children was 2 (1-4) days, the median gestational age was 38.3 (33-40 +4 ) weeks, and the median weight was 3.3 (2.2-4.8) kg. The detection rate of mNGS was 77.8% (14/18), higher than the 44.4% (8/18) of CMT ( P = 0.04). A total of 20 pathogens were detected in mNGS, with the top 3 most common pathogens being Klebsiella pneumoniae , Acinetobacter baumannii and Escherichia coli . Mixed infections were found in 14 cases (77.8%), including 13 cases (72.2%) with mixed infections detected by mNGS and 7 cases (27.8%) with mixed infections detected by CMT. A total of 9 children underwent treatment changes based on mNGS results and all of them experienced relief of symptoms. CONCLUSION Compared with CMT, mNGS can detect pathogens earlier and more sensitively, and may play an important role in ECMO-supported neonatal pneumonia pathogen detection and optimization of antibiotic therapy.
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Affiliation(s)
- Yi-Rong Zheng
- From the Department of Cardiac Surgery, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China
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Li X, Wang L, Li C, Wang X, Hao X, Du Z, Xie H, Yang F, Wang H, Hou X. A nomogram to predict nosocomial infection in patients on venoarterial extracorporeal membrane oxygenation after cardiac surgery. Perfusion 2024; 39:106-115. [PMID: 36172882 DOI: 10.1177/02676591221130484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION After cardiac surgery, patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have a higher risk of nosocomial infection in the intensive care unit (ICU). We aimed to establish an intuitive nomogram to predict the probability of nosocomial infection in patients on VA-ECMO after cardiac surgery. METHODS We included patients on VA-ECMO after cardiac surgery between January 2011 and December 2020 at a single center. We developed a nomogram based on independent predictors identified using univariate and multivariate logistic regression analyses. We selected the optimal model and assessed its performance through internal validation and decision-curve analyses. RESULTS Overall, 503 patients were included; 363 and 140 patients were randomly divided into development and validation sets, respectively. Independent predictors derived from the development set to predict nosocomial infection included older age, white blood cell (WBC) count abnormality, ECMO environment in the ICU, and mechanical ventilation (MV) duration, which were entered into the model to create the nomogram. The model showed good discrimination, with areas under the curve (95% confidence interval) of 0.743 (0.692-0.794) in the development set and 0.732 (0.643-0.820) in the validation set. The optimal cutoff probability of the model was 0.457 in the development set (sensitivity, 0.683; specificity, 0.719). The model showed qualified calibration in both the development and validation sets (Hosmer-Lemeshow test, p > .05). The threshold probabilities ranged from 0.20 to 0.70. CONCLUSIONS For adult patients receiving VA-ECMO treatment after cardiac surgery, a nomogram-monitoring tool could be used in clinical practice to identify patients with high-risk nosocomial infections and provide an early warning.
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Affiliation(s)
- Xiyuan Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of intensive care unit, Aviation General Hospital of China Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Jackson LB, Sobieszczyk MJ, Aden JK, Marcus JE. Fever and Leukocytosis Are Poor Predictors of Bacterial Coinfection in Patients With COVID-19 and Influenza Who Are Receiving Extracorporeal Membrane Oxygenation. Open Forum Infect Dis 2023; 10:ofad501. [PMID: 38023552 PMCID: PMC10644782 DOI: 10.1093/ofid/ofad501] [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: 04/12/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Background Fever and leukocytosis are 2 parameters commonly cited in clinical practice as indications to perform an infectious workup in patients receiving extracorporeal membrane oxygenation (ECMO), but their utility is unknown. Methods All patients who received ECMO between December 2014 and December 2020 with influenza or COVID-19 were included in this retrospective cohort study. Cultures were included if they were drawn from patients without signs of decompensation. Maximum temperature and white blood cell count were recorded on the day of culture collection. Workups with infections were compared with those that were negative. Results Of the 137 infectious workups in this 45-patient cohort, 86 (63%) were performed in patients with no signs of decompensation, totaling 165 cultures. These workups yielded 10 (12%) true infections. There were no differences in median (IQR) temperature (100.4 °F [100.2-100.8] vs 100.4 °F [99.3-100.9], P = .90) or white blood cell count (18.6 cells/mL [16.8-20.1] vs 16.7 cells/mL [12.8-22.3], P = .90) between those with and without infections. Conclusions In patients with influenza or COVID-19 who require ECMO, fever and leukocytosis were common indications for infectious workups, yet results were frequently negative. Despite their use in clinical practice, fever and leukocytosis are not reliable indicators of infection in patients who are hemodynamically stable and receiving ECMO.
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Affiliation(s)
- Luke B Jackson
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
| | - Michal J Sobieszczyk
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - James K Aden
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
| | - Joseph E Marcus
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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Tan C, Hota SS, Fan E, Marquis K, Vicencio E, Vaisman A. Bloodstream infection and ventilator-associated pneumonia in patients with coronavirus disease 2019 (COVID-19) supported by extracorporeal membrane oxygenation. Infect Control Hosp Epidemiol 2023; 44:1443-1450. [PMID: 36451285 PMCID: PMC10507515 DOI: 10.1017/ice.2022.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has been widely used in the care of patients with respiratory failure from coronavirus disease 2019 (COVID-19). We characterized bloodstream infections (BSIs) and ventilator-associated pneumonias (VAPs) in COVID-19 patients supported with ECMO, and we investigated their impact on patient outcomes. DESIGN Retrospective cohort study from March 1, 2020, to June 30, 2021. SETTING Academic tertiary-care referral center. PATIENTS Consecutive adult patients admitted for COVID-19 who received ECMO. METHODS We identified BSIs and VAPs and described their epidemiology and microbiology. Cumulative antimicrobial use and the specific management of BSIs were determined. Multivariate time-dependent Cox proportional hazards models were constructed to evaluate the impact of BSIs and VAPs on mortality, controlling for age, receipt of COVID-19-specific therapeutics, and new renal replacement therapy. RESULTS We identified 136 patients who received ECMO for COVID-19 pneumonia during the study period. BSIs and VAPs occurred in 81 patients (59.6%) and 93 patients (68.4%), respectively. The incidence of BSIs was 29.5 per 1,000 ECMO days and increased with duration of ECMO cannulation. Enterococci, Enterobacterales, and Staphylococcus aureus were the most common causes of BSIs, whereas S. aureus, Klebsiella species, and Pseudomonas aeruginosa comprised the majority of VAPs. Mean antibiotic use comprised 1,031 days of therapy per 1,000 ECMO days (SD, 496). We did not detect an association between BSIs or VAPs and mortality. CONCLUSIONS BSIs and VAPs are common in COVID-19 ECMO-supported patients. Efforts to optimize their diagnosis, prevention, and management should be prioritized.
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Affiliation(s)
- Charlie Tan
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Susy S. Hota
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Krista Marquis
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Elisa Vicencio
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Alon Vaisman
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
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Lyster H, Shekar K, Watt K, Reed A, Roberts JA, Abdul-Aziz MH. Antifungal Dosing in Critically Ill Patients on Extracorporeal Membrane Oxygenation. Clin Pharmacokinet 2023; 62:931-942. [PMID: 37300631 PMCID: PMC10338597 DOI: 10.1007/s40262-023-01264-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/12/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an established advanced life support system, providing temporary cardiac and/or respiratory support in critically ill patients. Fungal infections are associated with increased mortality in patients on ECMO. Antifungal drug dosing for critically ill patients is highly challenging because of altered pharmacokinetics (PK). PK changes during critical illness; in particular, the drug volume of distribution (Vd) and clearance can be exacerbated by ECMO. This article discusses the available literature to inform adequate dosing of antifungals in this patient population. The number of antifungal PK studies in critically ill patients on ECMO is growing; currently available literature consists of case reports and studies with small sample sizes providing inconsistent findings, with scant or no data for some antifungals. Current data are insufficient to provide definitive empirical drug dosing guidance and use of dosing strategies derived from critically patients not on ECMO is reasonable. However, due to high PK variability, therapeutic drug monitoring should be considered where available in critically ill patients receiving ECMO to prevent subtherapeutic or toxic antifungal exposures.
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Affiliation(s)
- Haifa Lyster
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- University of Portsmouth, Portsmouth, UK
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Kevin Watt
- School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON, N2G 1C5, Canada
- Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Anna Reed
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- Imperial College London, London, SW3 6NP, UK
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
- Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD, Australia.
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| | - Mohd-Hafiz Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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Li X, Wang X, Wang L, Li C, Hao X, Du Z, Xie H, Yang F, Wang H, Hou X. Impact of Nosocomial Infection on in-Hospital Mortality Rate in Adult Patients Under Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery. Infect Drug Resist 2023; 16:4189-4200. [PMID: 37404257 PMCID: PMC10315138 DOI: 10.2147/idr.s390599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/30/2023] [Indexed: 07/06/2023] Open
Abstract
Objective There was no consensus on the impact of nosocomial infection on In-hospital mortality rate in patients receiving ECMO. This study aimed to investigate the impact of nosocomial infection (NI) on In-hospital mortality rate in adult patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac surgery. Materials and Methods This retrospective study included 503 adult patients who underwent VA-ECMO after cardiac surgery. The impact of time-dependent NIs on In-hospital mortality rate within 28 days of ECMO initiation was investigated using a Cox regression model. The cumulative incidence function for death was compared between patients with NIs and those without NIs using a competing risk model. Results Within 28 days after ECMO initiation, 206 (41.0%) patients developed NIs, and 220 (43.7%) patients died. The prevalence rates of NIs were 27.8% and 20.3% during and after ECMO therapy, respectively. The incidence rates of NIs during and after ECMO therapy were 49‰ and 25‰, respectively. Time-dependent NI was an independent risk factor for predicting death (hazard ratio = 1.05, 95% confidence interval = 1.00-1.11). The cumulative incidence of death in patients with NI was significantly higher than that in patients without NI at each time point within 28 days of ECMO initiation. (Z = 5.816, P = 0.0159). Conclusion NI was a common complication in adult patients who received VA-ECMO after cardiac surgery, and time-dependent NI was an independent risk factor for predicting mortality in these patients. Using a competing risk model, we confirmed that NIs increased the risk of In-hospital mortality rate in these patients.
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Affiliation(s)
- Xiyuan Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
- Department of Intensive Care Unit, Aviation General Hospital of China Medical University, Beijing, 100012, People’s Republic of China
| | - Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
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Suzuki Y, Mao RMD, Shah NR, Schaeffer L, Deanda A, Radhakrishnan RS. Prevalence and Impact of Infection during Extracorporeal Membrane Oxygenation in Oncologic Patients: A Retrospective Analysis of the Extracorporeal Life Support Organization (ELSO) Registry. J Intensive Care Med 2023; 38:391-398. [PMID: 36128776 DOI: 10.1177/08850666221128243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Extracorporeal membrane oxygenation (ECMO) is widely utilized for severe cardiopulmonary insufficiency, but its application to the oncologic population has been debated given concern for increased risk of infection. This study aims to analyze the implications of infections acquired during ECMO runs in patients with malignancy. Methods: The Extracorporeal Life Support Organization (ELSO) database was queried for patients with an International Classification of Diseases code of neoplasms over the last two decades (2000-2019). Culture-proven infections during ECMO runs were analyzed and compared to previously reported data for all ECMO runs. Results: Two thousand, seven hundred and fifty-seven patients met inclusion criteria. Infection acquired during ECMO run was found in 687 patients, a significantly greater proportion compared to all ECMO runs (24.9% vs 11.7%; P = .001). Adult patients had a significantly higher rate of infection (27.0%; P < .001) compared to neonatal (11.0%) and pediatric (21.4%) patients. Prevalence of infection was highest in pulmonary ECMO (29.0%), while the infection rate standardized with ECMO duration was highest in extracorporeal cardiopulmonary resuscitation (55.03/1000-day ECMO run). Compared with ECMO for all diagnoses, the prevalence of Candida and Klebsiella infection was significantly higher in adult and pediatric oncologic patients. Regardless of the pathogen, the presence of infection was not associated with lower survival (38.6% vs 40.0%; P = .522). Conclusions: Oncologic patients had a significantly higher infection rate while on ECMO compared with the general ECMO population. However, the prognostic impact of these infections was minimal, thus ECMO should not be withheld in oncologic patients solely with concern for infection.
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Affiliation(s)
- Yota Suzuki
- Department of Surgery, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Rui-Min D Mao
- Department of Surgery, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Nikhil R Shah
- Department of Surgery, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Lawrence Schaeffer
- School of Medicine, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Abe Deanda
- Division of Cardiothoracic Surgery, Department of Surgery, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Ravi S Radhakrishnan
- Division of Pediatric Surgery, Department of Surgery, 12338University of Texas Medical Branch, Galveston, TX, USA
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Peitz GJ, Murry DJ. The Influence of Extracorporeal Membrane Oxygenation on Antibiotic Pharmacokinetics. Antibiotics (Basel) 2023; 12:500. [PMID: 36978367 PMCID: PMC10044059 DOI: 10.3390/antibiotics12030500] [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: 02/04/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming increasingly utilized to support critically ill patients who experience life-threatening cardiac or pulmonary compromise. The provision of this intervention poses challenges related to its complications and the optimization of medication therapy. ECMO's mechanical circulatory support is facilitated via various devices and equipment that have been shown to sequester lipophilic- and protein-bound medications, including anti-infectives. Since infectious outcomes are dependent on achieving specific anti-infectives' pharmacodynamic targets, the understanding of these medications' pharmacokinetic parameters in the setting of ECMO is important to clinicians. This narrative, non-systematic review evaluated the findings of the most recent and robust pharmacokinetic analyses for commonly utilized anti-infectives in the setting of ECMO. The data from available literature indicates that anti-infective pharmacokinetic parameters are similar to those observed in other non-ECMO critically ill populations, but considerable variability in the findings was observed between patients, thus prompting further evaluation of therapeutic drug monitoring in this complex population.
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Affiliation(s)
- Gregory J. Peitz
- Nebraska Medicine, Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Daryl J. Murry
- Clinical Pharmacology Laboratory, Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Tantway TM, Arafat AA, Albabtain MA, Belghith M, Osman AA, Aboughanima MA, Abdullatif MT, Elshoura YA, AlBarak MM. Sepsis in postcardiotomy cardiogenic shock patients supported with veno- arterial extracorporeal membrane oxygenation. Int J Artif Organs 2023; 46:153-161. [PMID: 36744676 DOI: 10.1177/03913988231152978] [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] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sepsis could affect the outcomes of patients with postcardiotomy cardiogenic shock supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to characterize sepsis patients with ECMO support for postcardiotomy cardiogenic shock and assess its predictors and effect on patients' outcomes. METHODS This retrospective study included 103 patients with ECMO for postcardiotomy cardiogenic shock from 2009 to 2020. Patients were divided according to the occurrence and timing of sepsis into three groups. Group 1 included patients with no sepsis (n = 67), Group 2 included patients with ECMO-related sepsis (n = 10), and Group 3 included patients with non-ECMO-related sepsis (n = 26). RESULTS Lactate level before ECMO was highest in the ECMO-associated sepsis group (Group 1 and 2 p = 0.003 and Group 2 and 3 p = 0.003). Dialysis and gastrointestinal bleeding were highest in ECMO-associated sepsis (p = 0.03 and 0.04, respectively). Blood transfusion was higher in ECMO-associated sepsis than in patients with no sepsis (p = 0.01). Mortality was nonsignificantly higher in patients with ECMO-associated sepsis. High BMI (OR: 1.11; p = 0.004), preoperative dialysis (OR: 7.35; p = 0.02), preoperative IABP (OR: 9.9.61; p = 0.01) and CABG (OR: 6.29; p = 0.01) were significantly associated with sepsis. Older age (OR: 1.08; p = 0.004), lower BSA (OR: 0.004; p = 0.003), peripheral cannulation (OR: 29.82; p = 0.03), and high pre ECMO lactate level (OR: 1.24; p = 0.001) were associated with increased mortality. Sepsis did not predict mortality (OR: 1.83; p = 0.21). CONCLUSIONS Sepsis is a dreaded complication in patients with postcardiotomy cardiogenic shock, especially ECMO-associated sepsis. Preoperative risk factors could predict postoperative sepsis in ECMO patients.
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Affiliation(s)
- Tarek M Tantway
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Intensive Care Department, Cairo University, Cairo, Egypt
| | - Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy Department, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Makhlouf Belghith
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Ahmed A Osman
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Intensive Care Department, Cairo University, Cairo, Egypt
| | | | | | - Youssef A Elshoura
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Anesthesia and Critical Care Department, Tanta University, Tanta, Egypt
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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11
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Abstract
Fungal infections are common and frequently associated with clinical failure in patients receiving extracorporeal membrane oxygenation (ECMO). Antifungal drugs have physicochemical characteristics associated with a higher likelihood of sequestration onto ECMO circuitry potentially leading to a subtherapeutic drug concentration. The percentage of sequestration of the antifungal drugs-caspofungin, posaconazole, and voriconazole-was determined using an ex vivo ECMO model. The circuits were primed with whole human blood, sodium chloride 0.9%, and human albumin solution. Serial 2 ml samples were taken at baseline, 0.5, 1, 2, 6, 12, and 24 hours after drug addition, paired with non-ECMO controls stored in a water bath at 37°C. Mean loss from the blood-primed ECMO circuits and controls at 24 hours relative to baseline were 80% and 61% for caspofungin ( p = ns), 64% and 11% for posaconazole ( p < 0.005), and 27% and 19% for voriconazole ( p < 0.05). Calculated AUC 0-24 showed a 44% for caspofungin ( p = ns), 30.6% posaconazole ( p < 0.005), and 9% loss for voriconazole ( p = 0.003) compared with the controls, suggesting therapeutic concentrations of these antifungal agents cannot be guaranteed with standard dosing in patients on ECMO. Posaconazole exhibited the greatest loss to the ECMO circuit correlating with both high lipophilicity and protein binding of the drug.
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12
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Infection profile of patients with extracorporeal membrane oxygenation in paediatric cardiac surgery ICU. Cardiol Young 2022; 32:1833-1838. [PMID: 35481466 DOI: 10.1017/s1047951122001263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM We investigated the risk of increased nosocomial infections and the associated pathogens in patients who underwent paediatric cardiovascular surgery and were put on extracorporeal membrane oxygenation support. We studied the duration of extracorporeal membrane oxygenation use and other variables that may be associated with increased nosocomial infection risk. METHODS Patients who were treated with an extracorporeal membrane oxygenation in paediatric cardiovascular surgery ICU between 2010 and 2020 were included in this retrospective study. We analysed the site of infection and microbiological profile of infections occurring in these patients according to CDC and National Healthcare Safety Network criteria. RESULTS The onset of infection development in patients after extracorporeal membrane oxygenation was found to be median 8 (3-15, 25-75 IQR) days in the whole group, and median 11 (3-16, 25-75 IQR) days in those who developed infection without being put on extracorporeal membrane oxygenation. When patients were divided into those with and without infection, duration of ICU was found to be 19 (16-28, IQR 25-75) days in patients with infection vs. 8 (2-16, IQR 25-75; p: <0.001) days in patients without infection. Duration of extracorporeal membrane oxygenation support was found to be 14 (10-25, IQR 25-75) days in patients with infection versus 5 (2-10, IQR 25-75; p: <0.001) days in patients without infection and total hospital stay was 26 (18-33, IQR 25-75) days in patients with infection versus 8 (2-23, IQR 25-75) days in those without infection. A total of 24 patients out of the 70 patients experienced 32 infectious episodes during extracorporeal membrane oxygenation support. Culture-positive infections were detected at a single site in 19 patients, and multiple sites in 5 patients. CONCLUSION We propose that prolonged extracorporeal membrane oxygenation support is associated with an increased risk of infection. Although extracorporeal membrane oxygenation is a life-saving treatment method, prolonged extracorporeal membrane oxygenation may increase the development of infectious complications and the associated mortality and morbidity of the patient.
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13
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Rajsic S, Treml B, Jadzic D, Breitkopf R, Oberleitner C, Popovic Krneta M, Bukumiric Z. Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications. Ann Intensive Care 2022; 12:93. [PMID: 36195759 PMCID: PMC9532225 DOI: 10.1186/s13613-022-01067-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock. METHODS We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size. RESULTS Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality. CONCLUSIONS Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, Cagliari, Italy
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Christoph Oberleitner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | | | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000, Belgrade, Serbia.
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14
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Yang L, Li M, Gu S, Feng Y, Huang X, Zhang Y, Tian Y, Wu X, Zhan Q, Huang L. Risk factors for bloodstream infection (BSI) in patients with severe acute respiratory distress syndrome (ARDS) supported by veno-venous extracorporeal membrane oxygenation (VV-ECMO). BMC Pulm Med 2022; 22:370. [PMID: 36171599 PMCID: PMC9518943 DOI: 10.1186/s12890-022-02164-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background There were relatively few studies about the incidence and risk factors for bloodstream infection (BSI) in patients with severe acute respiratory distress syndrome (ARDS) supported by veno–venous extracorporeal membrane oxygenation (VV–ECMO).
Methods Patients who were diagnosed with severe ARDS and received VV–ECMO treatment in the medical intensive care unit of China–Japan Friendship Hospital from August 2013 to March 2019 were retrospectively studied. The pathogens isolated from blood culture (BC) were identified and analyzed for drug sensitivity. The risk factors for BSI were analyzed by logistic regression.
Results A total of 105 patients were included in this single–center retrospective cohort study. Among them, 23 patients (22%) had BSIs. 19 cases were identified as primary BSI; while the other 4 cases were as secondary BSI. A total of 23 pathogenic strains were isolated from BCs, including gram–negative (G–) bacilli in 21 (91%) cases, gram–positive (G+) cocci in 1 case, fungus in 1 case, and multidrug–resistant (MDR) organisms in 8 cases. Compared with patients without BSI, patients with BSI had a higher Murray score (odds ratio = 6.29, P = 0.01) and more blood transfusion (odds ratio = 1.27, P = 0.03) during ECMO. Conclusions The incidence of BSI in patients with severe ARDS supported by VV–ECMO was 22%. G– bacilli was the main pathogen, and most of them were MDR–G– bacilli (MDR–GNB). Higher Murray score and more blood transfusion may be the independent risk factors for BSI.
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Affiliation(s)
- Liuting Yang
- NHC Key Laboratory of Pneumoconiosis, Shanxi Province Key Laboratory of Respiratory, Department of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yingying Feng
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xu Huang
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yi Zhang
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Ye Tian
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xiaojing Wu
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Linna Huang
- Department of Pulmonary and Critical Care Medicine, National Center of Respiratory Medicine, China-Japan Friendship Hospital, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.
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15
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Fischer S, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan AJ, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Goesdonk H, Ferrari MW, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel LM, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Ensminger S, Kelm M, Boeken U. Empfehlungen der S3-Leitlinie (AWMF) „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“. Zentralbl Chir 2022. [DOI: 10.1055/a-1918-1999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
ZusammenfassungIn den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile
jährlich etwa 3000 ECLS-/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter
Empfehlungen zu den zentralen Aspekten der ECLS-/ECMO-Therapie. Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und
Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit
Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter
Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde. Die Leitlinie fokussiert auf
klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht
zu der Methodik und den konsentierten Empfehlungen.
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Affiliation(s)
- Stefan Fischer
- Klinik für Thoraxchirurgie und Lungenunterstützung, Klinikum Ibbenbüren, Ibbenbüren, Deutschland
| | - Alexander Assmann
- Herzchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Andreas Beckmann
- Klinik für Herz- und Gefäßchirurgie, Herzzentrum Duisburg, Duisburg, Deutschland
| | - Christof Schmid
- Klinik und Poliklinik für Herz-, Thorax- und herznahe Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Karl Werdan
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Halle, Deutschland
| | - Guido Michels
- Akut- und Notfallmedizin, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Oliver Miera
- Klinik für Angeborene Herzfehler – Kinderkardiologie, Deutsches Herzzentrum Berlin, Berlin, Deutschland
| | | | - Stefan Klotz
- Herzchirurgie, Segeberger Kliniken GmbH, Bad Segeberg, Deutschland
| | - Christoph Starck
- Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Berlin, Deutschland
| | - Kevin Pilarczyk
- Klinik für Intensivmedizin, imland Klinik Rendsburg, Rendsburg, Deutschland
| | | | - Marion Burckhardt
- Angewandte Gesundheitswissenschaften für Pflege, insbes. Pflegewissenschaften u. klinische Praxis, DHBW, Stuttgart, Deutschland
| | - Monika Nothacker
- Philipps-Universität Marburg, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften eV, Marburg, Deutschland
| | - Ralf Muellenbach
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Kassel GmbH, Kassel, Deutschland
| | - York Zausig
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Deutschland
| | - Nils Haake
- Klinik für Intensivmedizin, imland Klinik Rendsburg, Rendsburg, Deutschland
| | - Heinrich Goesdonk
- Klinik für Interdisz. Intensivmedizin und Intermediate Care, HELIOS Klinikum Erfurt, Erfurt, Deutschland
| | - Markus Wolfgang Ferrari
- Klinik für Innere Medizin I: Kardiologie und konservative Intensivmedizin, DKD HELIOS Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Michael Buerke
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Marien Kliniken Siegen, Siegen, Deutschland
| | - Marcus Hennersdorf
- Klinik für Innere Medizin I: Kardiologie, Angiologie, Pneumologie, Internistische Intensivmedizin, SLK-Kliniken Heilbronn GmbH, Heilbronn, Deutschland
| | - Mark Rosenberg
- Medizinische Klinik I, Kardiologie, Nephrologie, Pneumologie, Rhythmologie, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Deutschland
| | - Thomas Schaible
- Klinik für Neonatologie, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Harald Köditz
- Klinik für Pädiatrische Kardiologie und Pädiatrische Intensivmedizin, Medizinische Hochschule Hannover Klinikum, Hannover, Deutschland
| | - Stefan Kluge
- Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Innere Medizin und Internistische Intensivmedizin, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Matthias Lubnow
- Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Andreas Flemmer
- Leiter der Neonatologie am Perinatalzentrum Großhadern, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Susanne Herber-Jonat
- Kinder- und Jugendmedizin, Neonatologie, Dr von Haunersches Kinderspital Kinderklinik und Kinderpoliklinik der Ludwig Maximilian Universitat Munchen, Munchen,
Deutschland
| | - Lucas M Wessel
- Zentrums für Kinder-, Jugend- und rekonstruktive Urologie, Universitätsklinikum Mannheim Klinik für Kinder- und Jugendmedizin, Mannheim, Deutschland
| | - Dirk Buchwald
- Herz- und Thoraxchirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Sven Maier
- Herz- und Gefäßchirurgie, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Deutschland
| | - Lars Krüger
- Pflegeentwicklung, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland
| | - Andreas Fründ
- Physiotherapie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland
| | - Rolf Jaksties
- Ehrenamtlicher Beauftragter, Deutsche Herzstiftung e.V., Frankfurt am Main, Deutschland
| | - Karsten Wiebe
- Herz-und Thoraxchirurgie, Sektion Thoraxchirurgie, Universitätsklinikum Münster, Munster, Deutschland
| | - Christiane Hartog
- Versorgungsforschung, Charité Universitätsmedizin Berlin CVK, Berlin, Deutschland
| | - Omer Dzemali
- Klinik für Herzchirurgie, Stadtspital Triemli, Zürich, Schweiz
| | - Daniel Zimpfer
- Kinder- und Jugendheilkunde, Meduni Graz, Graz, Österreich
| | - Elfriede Ruttmann-Ulmer
- Klinik für Herzchirurgie, Medizinische Universität Innsbruck Universitätsklinik für Herzchirurgie, Innsbruck, Österreich
| | - Christian Schlensak
- Universitätsklinik für Herz, Thorax- und Gefäßchirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Stephan Ensminger
- Klinik für Herz- und thorakale Gefäßchirurgie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Malte Kelm
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Udo Boeken
- Klinik für Herzchirurgie/Leiter des Transplantationsprogramms, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Deutschland
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16
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Shih E, Michael DiMaio J, Squiers JJ, Banwait JK, Kussman HM, Meyers DP, Meidan TG, Sheasby J, George TJ. Bloodstream and respiratory coinfections in patients with COVID-19 on ECMO. J Card Surg 2022; 37:3609-3618. [PMID: 36073136 PMCID: PMC9538542 DOI: 10.1111/jocs.16909] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID-19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. METHODS This is a retrospective analysis of patients with COVID-19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. RESULTS Of 44 patients placed on ECMO support for COVID-19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p = .02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20-39.5] days; p = .03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5-43.3]; p = .02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p = .46) or Kaplan-Meier survival (logrank p = .82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2-67.2)% at 15 days from ECMO initiation. CONCLUSIONS There is a high rate of co-infections in patients placed on ECMO for COVID-19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior.
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Affiliation(s)
- Emily Shih
- Department of General Surgery, Baylor University Medical Center, Dallas, Texas, USA.,Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - J Michael DiMaio
- Baylor Scott and White Research Institute, Dallas, Texas, USA.,Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - John J Squiers
- Department of General Surgery, Baylor University Medical Center, Dallas, Texas, USA.,Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | | | - Howard M Kussman
- Infectious Disease, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - David P Meyers
- Critical Care Medicine, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - Talia G Meidan
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Jenelle Sheasby
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Timothy J George
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
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17
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Lee EH, Lee KH, Lee SJ, Kim J, Baek YJ, Ahn JY, Jeong SJ, Ku NS, Choi JY, Yeom JS, Song YG, Kim JH. Clinical and microbiological characteristics of and risk factors for bloodstream infections among patients with extracorporeal membrane oxygenation: a single-center retrospective cohort study. Sci Rep 2022; 12:15059. [PMID: 36064957 PMCID: PMC9445101 DOI: 10.1038/s41598-022-19405-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides hemodynamic and oxygenation support to critically ill patients. Due to multiple catheter cannulations, patients on ECMO are vulnerable to bloodstream infections (BSIs). We aimed to investigate the incidence, clinical characteristics, risk factors, and microorganisms associated with BSIs during ECMO. This single-center retrospective cohort study was conducted between January 2015 and May 2021. Patients aged 18 years or older with an ECMO duration of > 48 h for cardiogenic or respiratory support were included in the study. Patients who developed bacteremia or candidemia from 12 h after ECMO cannulation to 7 days after de-cannulation were included. The clinical factors between non-BSI and BSI were compared, along with an analysis of the risk factors associated with BSI during ECMO. A total of 480 patients underwent ECMO for cardiogenic shock (n = 267, 55.6%) or respiratory failure (n = 213, 44.4%) during the study period. The incidence was 20.0 episodes per 1000 ECMO-days. Approximately 20.2% (97/480) and 5.4% (26/480) of the patients developed bacteremia and candidemia, respectively. The median numbers of days of BSI development were 8.00 days for bacteremia and 11.0 days for candidemia. The most common pathogens were methicillin-resistant coagulase-negative staphylococci (n = 24), followed by vancomycin-resistant Enterococcus (n = 21). Multivariable logistic analysis demonstrated that hemodialysis (odds ratio [OR] 2.647, p < 0.001), veno-arterial-venous mode (OR 1.911, p = 0.030), and total ECMO duration (OR 1.030, p = 0.007) were significant risk factors for bacteremia. The total ECMO duration was the only risk factor associated with candidemia (OR 1.035, p = 0.010). The mortality rate was significantly higher in the bacteremia (57.7%) and candidemia (69.2%) groups than that in the non-BSI group (43.6%). BSI is a common complication of patients receiving ECMO support and is associated with poor clinical outcomes. Determining the type of frequently isolated organisms and the median onset time of BSI would help in the selection of appropriate prophylactic antibiotics or antifungal agents.
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Affiliation(s)
- Eun Hwa Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Ki Hyun Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Se Ju Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jinnam Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Yae Jee Baek
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jin Young Ahn
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Nam Su Ku
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Young Goo Song
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722.
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Li X, Wang L, Wang H, Hou X. Outcome and Clinical Characteristics of Nosocomial Infection in Adult Patients Undergoing Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. Front Public Health 2022; 10:857873. [PMID: 35812481 PMCID: PMC9268548 DOI: 10.3389/fpubh.2022.857873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022] Open
Abstract
Objective This study conducts a meta-analysis of clinical outcomes of nosocomial infection in adult patients receiving extracorporeal membrane oxygenation (ECMO) and systematically evaluates clinical epidemiological characteristics. Methods Document retrieval strategies were determined, and all adult patients treated by ECMO were included. The prevalence, incidence, mortality, ECMO use time, intensive care unit (ICU) stay time, hospital stay time, and risk factors of nosocomial infection were systematically evaluated. Subsequently, a meta-analysis of the impact of nosocomial infection on risk of in-hospital mortality was conducted. Results A total of 25 retrospective studies were included, and 19 studies were included in the meta-analysis. The prevalence of nosocomial infection was 8.8–64.0%, incidence was 1.7–85.4‰ (per 1,000 ECMO days), and in-hospital mortality was 31.5–75.4%. The duration of ECMO usage and length of ICU stay were longer for infected patients. Compared with non-infected patients, the meta-analysis revealed that nosocomial infection increased the relative risk of death of adult patients receiving ECMO by 32%. The risk factors included the duration of ECMO usage and disease severity score. Conclusions Adult patients treated by ECMO have high prevalence of nosocomial infection. In addition, their ECMO use time and ICU stays are longer. Nosocomial infection significantly increases the relative risk of in-hospital mortality.
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Affiliation(s)
- Xiyuan Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care Unit, Aviation General Hospital of China Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- *Correspondence: Xiaotong Hou
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19
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Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Ensminger S, Kelm M, Boeken U. Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1734-4157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungIn den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland
mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der
Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der
Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und
der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der
extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen.
Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.
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Affiliation(s)
- Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St. Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken Bad Segeberg, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic & Vascular Surgery, German Heart Centre, Berlin, Deutschland
| | - Kevin Pilarczyk
- Department for Intensice Care Medicine, Imland Hospital Rendsburg, Rendsburg, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW)-Stuttgart, Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Germany
| | - Nils Haake
- Department for Intensice Care Medicine, Imland Hospital Rendsburg, Rendsburg, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Medizinische Klinik I, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Harald Köditz
- Medical University Children's Hospital Hannover, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, München, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, München, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Deutschland
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University Bochum, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University Bochum, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Zürich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
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Population Pharmacokinetics and Dosing Optimization of Piperacillin-Tazobactam in Critically Ill Patients on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy. Microbiol Spectr 2021; 9:e0063321. [PMID: 34937189 PMCID: PMC8694146 DOI: 10.1128/spectrum.00633-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Critical illness and extracorporeal circulation, such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), may alter the pharmacokinetics of piperacillin-tazobactam. We aimed to develop a population pharmacokinetic model of piperacillin-tazobactam in critically ill patients during ECMO or CRRT and investigate the optimal dosage regimen needed to achieve ≥90% of patients attaining the piperacillin pharmacodynamic target of 100% of dosage time above MIC of 16 mg/L. This prospective observational study included 26 ECMO patients, of which 13 patients received continuous venovenous hemodiafiltration (CVVHDF). A population pharmacokinetic model was developed using nonlinear mixed-effects models, and Monte Carlo simulations were performed to evaluate creatinine clearance (CrCL) and infusion method in relation to the probability of target attainment (PTA) in four patient groups according to combination of ECMO and CVVHDF. A total of 244 plasma samples were collected. In a two-compartment model, clearance decreased during ECMO and CVVHDF contributed to an increase in the volume of distribution. The range of PTA reduction as CrCL increased was greater in the order of intermittent bolus, extended infusion, and continuous infusion method. Continuous infusion should be considered in critically ill patients with CrCL of ≥60 mL/min, and at least 12, 16, and 20 g/day was required for CrCL of <40, 40 to 60, and 60 to 90 mL/min, respectively, regardless of ECMO or CVVHDF. In patients with CrCL of ≥90 mL/min, even a continuous infusion of 24 g/day was insufficient to achieve adequate PTA. Therefore, further research on permissible high continuous infusion dose focused on the risk of toxicity is required. (This trial has been registered at ClinicalTrials.gov under registration no. NCT02581280, December 1, 2014.) IMPORTANCE To the best of our knowledge, this is the first large prospective pharmacokinetic/pharmacodynamic (PK/PD) study of piperacillin-tazobactam in ECMO patients. We used piperacillin-tazobactam plasma concentration data from four different cases (concomitant use of ECMO and CVVHDF, receiving ECMO only, weaned from ECMO and receiving CVVHDF, and weaned from ECMO and not receiving CVVHDF) to provide preliminary insights into the incremental effects of critical illness, ECMO, and CVVHDF on PK. Our analysis revealed that volume of distribution increased in patients on CVVHDF and clearance decreased during ECMO and as creatinine clearance was reduced. When targeting 100% fT>MIC (16 mg/L, clinical breakpoint for Pseudomonas aeruginosa), continuous infusions would have achieved the highest percentage of target attainment compared to intermittent bolus or extended infusion if the total daily dose was the same. Continuous infusion should be considered in critically ill patients with creatinine clearance of ≥60 mL/min, regardless of ECMO or CVVHDF.
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21
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Boeken U, Ensminger S, Assmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Beckmann A. Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S, Boeken U. Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice Guideline Level 3. ESC Heart Fail 2021; 9:506-518. [PMID: 34811959 PMCID: PMC8788014 DOI: 10.1002/ehf2.13718] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022] Open
Abstract
Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno‐arterial extracorporeal membrane oxygenation (va‐ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio‐economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment. Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements. Conclusions This first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.
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Affiliation(s)
- Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Moorenstr. 5, Düsseldorf, 40225, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, Germany
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshader, LMU Munich, Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa, Germany
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Medical Faculty, Moorenstr. 5, Düsseldorf, 40225, Germany
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23
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Boeken U, Ensminger S, Assmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Beckmann A. [Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]. Med Klin Intensivmed Notfmed 2021; 116:678-686. [PMID: 34665281 DOI: 10.1007/s00063-021-00868-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.
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Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Deutschland
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Deutschland
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle-Wittenberg, Deutschland
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Deutschland
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Deutschland
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Deutschland
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Deutschland
| | - Kevin Pilarczyk
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps University Hospital Marburg, Marburg, Deutschland
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW)-Stuttgart, Stuttgart, Deutschland
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Deutschland
| | - Ralf Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Deutschland
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Deutschland
| | - Nils Haake
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, 99089, Erfurt, Deutschland
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Deutschland
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Deutschland
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Deutschland
| | - Mark Rosenberg
- Department of Internal Medicine I, Hospital Aschaffenburg-Alzenau, Aschaffenburg-Alzenau, Deutschland
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Deutschland
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Deutschland
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Deutschland
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Deutschland
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Deutschland
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr University, Bochum, Deutschland
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Deutschland
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University, Bochum, Deutschland
| | - Andreas Fründ
- Department of Physiotherapy, Heart and Diabetes Center NRW, Ruhr University, Bochum, Bochum, Deutschland
| | - Rolf Jaksties
- German Heart Foundation, Frankfurt am Main, Deutschland
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Deutschland
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Deutschland
| | - Christiane Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Birmensdorferstraße 497, 8063, Zurich, Schweiz
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Österreich
| | - Elfriede Ruttmann-Ulmer
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Deutschland
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical School, Moorenstraße 5, Duesseldorf, Deutschland
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Luisenstraße 58/59, Berlin, Deutschland
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Boeken U, Ensminger S, Assmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog C, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Beckmann A. [Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]. Anaesthesist 2021; 70:942-950. [PMID: 34665266 DOI: 10.1007/s00101-021-01058-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.
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Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Deutschland
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Deutschland
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle-Wittenberg, Deutschland
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Deutschland
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Deutschland
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Deutschland
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Deutschland
| | - Kevin Pilarczyk
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps University Hospital Marburg, Marburg, Deutschland
| | - Marion Burckhardt
- Department of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University (DHBW)-Stuttgart, Stuttgart, Deutschland
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Deutschland
| | - Ralf Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Deutschland
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Deutschland
| | - Nils Haake
- Imland Hospital Rendsburg, Department for Intensive Care Medicine, Rendsburg, Schleswig-Holstein, Deutschland
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, 99089, Erfurt, Deutschland
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Deutschland
| | - Michael Buerke
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Deutschland
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Deutschland
| | - Mark Rosenberg
- Department of Internal Medicine I, Hospital Aschaffenburg-Alzenau, Aschaffenburg-Alzenau, Deutschland
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Deutschland
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Deutschland
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Deutschland
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Deutschland
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich-Grosshadern, LMU Munich, Munich, Deutschland
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Deutschland
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr University, Bochum, Deutschland
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Deutschland
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University, Bochum, Deutschland
| | - Andreas Fründ
- Department of Physiotherapy, Heart and Diabetes Center NRW, Ruhr University, Bochum, Bochum, Deutschland
| | - Rolf Jaksties
- German Heart Foundation, Frankfurt am Main, Deutschland
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Deutschland
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Deutschland
| | - Christiane Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City Hospital Zurich, Birmensdorferstraße 497, 8063, Zurich, Schweiz
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Österreich
| | - Elfriede Ruttmann-Ulmer
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University of Tübingen, Tübingen, Deutschland
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical School, Moorenstraße 5, Duesseldorf, Deutschland
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Luisenstraße 58/59, Berlin, Deutschland
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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Selçuk ÜN, Sargın M, Baştopçu M, Mete EMT, Erdoğan SB, Öcalmaz Ş, Orhan G, Aka SA. Microbiological Spectrum of Nosocomial ECMO Infections in a Tertiary Care Center. Braz J Cardiovasc Surg 2021; 36:338-345. [PMID: 33355788 PMCID: PMC8357375 DOI: 10.21470/1678-9741-2020-0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment in cardiogenic and respiratory shock. It is prone to various complications, infection being among the most frequent. This study aims to define the prevalence and characteristics of infections in ECMO patients in a tertiary care center for cardiac diseases. METHODS All ECMO patients between 2012 and 2016 in a single cardiac center were retrospectively included. Demographic data, ECMO indications, type, site, duration, and infection-related data were recorded. Data were analyzed among all patients and separately between pediatric and adult patient groups. RESULTS One hundred and twenty-six patients, 66 (53.4%) pediatric and 60 (47.6%) adult, received ECMO within the study period. Mean age was 3.54±4.27 years in the pediatric group and 54.92±15.57 years in the adult group. The main indication for ECMO was postcardiotomy shock (77.8%). Forty-six (36.5%) of all cases developed a culture-proven nosocomial infection with a rate of 49/1000 ECMO days. Infection was associated with > 5 days of ECMO duration and hemodialysis requirement in all patients and lower age in the pediatric group. The most frequent infection site was the lower respiratory tract (14.3%), while the most common isolated organisms were Klebsiella (8.7%) and Streptococcus (4.8%) species. CONCLUSION The respiratory tract is the most common site of infection, however, all sites impose a threat to recovery, with longer treatment durations required for patients with culture-proven infections. A better understanding of the infectious spectrum and its effect on the mortality and morbidity is required for more successful treatment of ECMO patients.
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Affiliation(s)
- Ümmühan Nehir Selçuk
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Sargın
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Baştopçu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Evren Müge Taşdemir Mete
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç Bayer Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Şeyda Öcalmaz
- Department of Infectious Diseases and Clinical Microbiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gökçen Orhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Wang J, Huang J, Hu W, Cai X, Hu W, Zhu Y. Risk factors and prognosis of nosocomial pneumonia in patients undergoing extracorporeal membrane oxygenation: a retrospective study. J Int Med Res 2021; 48:300060520964701. [PMID: 33086927 PMCID: PMC7585896 DOI: 10.1177/0300060520964701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective We aimed to examine the risk factors and prognosis of nosocomial pneumonia (NP) during extracorporeal membrane oxygenation (ECMO). Methods We retrospectively analyzed data of patients who received ECMO at the Affiliated Hangzhou Hospital of Nanjing Medical University between January 2013 and August 2019. The primary outcome was the survival-to-discharge rate. Results Sixty-nine patients who received ECMO were enrolled, median age 42 years and 26 (37.7%) women; 14 (20.3%) patients developed NP. The NP incidence was 24.7/1000 ECMO days. Patients with NP had a higher proportion receiving veno-venous (VV) ECMO (50% vs. 7.3%); longer ECMO support duration (276 vs. 140 hours), longer ventilator support duration before ECMO weaning (14.5 vs. 6 days), lower ECMO weaning success rate (50.0% vs. 81.8%), and lower survival-to-discharge rate (28.6% vs. 72.7%) than patients without NP. Multivariable analysis showed independent risk factors that predicted NP during ECMO were ventilator support duration before ECMO weaning (odds ratio [OR] = 1.288; 95% confidence interval [CI]: 1.111–1.494) and VV ECMO mode (OR = 10.970; 95% CI: 1.758–68.467). Conclusion NP during ECMO was associated with ventilator support duration before ECMO weaning and VV ECMO mode. Clinicians should shorten the respiratory support duration for patients undergoing ECMO to prevent NP.
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Affiliation(s)
- Jianrong Wang
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Jinyu Huang
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Wei Hu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Xueying Cai
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Weihang Hu
- Department of Critical Care Medicine, Zhejiang Hospital, Zhejiang, China
| | - Ying Zhu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
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29
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Different characteristics of bloodstream infection during venoarterial and venovenous extracorporeal membrane oxygenation in adult patients. Sci Rep 2021; 11:9498. [PMID: 33947970 PMCID: PMC8097062 DOI: 10.1038/s41598-021-89108-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/21/2021] [Indexed: 01/05/2023] Open
Abstract
Currently, there is scarcity of data on whether differences exist in clinical characteristics and outcomes of bloodstream infection (BSI) between venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) and whether they differ between Candida BSI and bacteremia in adult ECMO patients. We retrospectively reviewed data of patients who required ECMO for > 48 h and had BSIs while receiving ECMO between January 2015 and June 2020. Cases with a positive blood culture result within 24 h of ECMO implantation were excluded. We identified 94 (from 64 of 194 patients) and 38 (from 17 of 56 patients) BSI episodes under VA and VV ECMO, respectively. Fifty nine BSIs of VA ECMO (59/94, 62.8%) occurred in the first 2 weeks after ECMO implantation, whereas 24 BSIs of VV ECMO (24/38, 63.2%) occurred after 3 weeks of ECMO implantation. Gram-negative bacteremia (39/59, 66.1%) and gram-positive bacteremia (10/24, 41.7%) were the most commonly identified BSI types in the first 2 weeks after VA ECMO implantation and after 3 weeks of VV implantation, respectively. Timing of Candida BSI was early (6/11, 54.5% during the first 2 weeks) in VA ECMO and late (6/9, 66.7% after 3 weeks of initiation) in VV ECMO. Compared with bacteremia, Candida BSI showed no differences in clinical characteristics and outcomes during VA and VV ECMO, except the significant association with prior exposure to carbapenem in VA ECMO (vs. gram-negative bacteremia [P = 0.006], vs. gram-positive bacteremia [P = 0.03]). Our results suggest that ECMO modes may affect BSI clinical features and timing. In particular, Candida BSI occurrence during the early course of VA ECMO is not uncommon, especially in patients with prior carbapenem exposure; however, it usually occurs during the prolonged course of VV ECMO. Consequently, routine blood culture surveillance and empiric antifungal therapy might be warranted in targeted populations of adult ECMO patients, regardless of levels of inflammatory markers and severity scores.
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Yun JH, Hong SB, Jung SH, Kang PJ, Sung H, Kim MN, Kim SH, Lee SO, Choi SH, Woo JH, Kim YS, Chong YP. Epidemiology and Clinical Characteristics of Bloodstream Infection in Patients Under Extracorporeal Membranous Oxygenation. J Intensive Care Med 2020; 36:1053-1060. [PMID: 33375874 DOI: 10.1177/0885066620985538] [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: 11/16/2022]
Abstract
BACKGROUND Bloodstream infection (BSI) is an important complication of extracorporeal membranous oxygenation (ECMO) and a major cause of mortality. This study evaluated the epidemiological and clinical characteristics of BSI that occur during ECMO application according to microbial etiology. METHODS Adult patients who underwent ECMO from January 2009 to December 2016 were retrospectively analyzed for BSI episodes at a 2,700-bed, tertiary center. Epidemiological and clinical characteristics and outcomes of BSI were evaluated and were compared for etiologic groups (gram-positive cocci, gram-negative rods, and fungi groups). Risk factors for 14-day mortality were analyzed. RESULTS A total of 1,100 patients underwent ECMO during the study period, and 65 BSI episodes occurred in 61 patients. The BSI incidence was 8.3 episodes/1,000 ECMO days, which significantly decreased over time (P = 0.03), primarily in gram-positive cocci BSI. Gram-positive cocci, gram-negative rods, and fungi accounted for 38%, 40%, and 22% of the 73 blood isolates, respectively. Baseline characteristics were comparable between groups. Catheter-related infection (CRI) and pneumonia were the most common sources of BSI; 52% of gram-positive cocci BSIs and 79% of fungi BSIs were caused by CRI, and 75% of gram-negative BSIs by pneumonia. Patients with gram-negative rods BSI died more frequently and earlier than those with other BSIs. Independent risk factors for 14-day mortality were older age and gram-negative rods BSI. CONCLUSIONS The decreased BSI incidence during ECMO was mainly because of the decrease of gram-positive cocci BSI. The high early mortality of gram-negative rods BSI makes prevention and adequate treatment necessary.
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Affiliation(s)
- Ji Hyun Yun
- Department of Infectious Diseases, 119754Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea.,Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Pil Je Kang
- Department of Thoracic and Cardiovascular Surgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang-Soo Kim
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Ko RE, Huh K, Kim DH, Na SJ, Chung CR, Cho YH, Jeon K, Suh GY, Yang JH. Nosocomial infections in in-hospital cardiac arrest patients who undergo extracorporeal cardiopulmonary resuscitation. PLoS One 2020; 15:e0243838. [PMID: 33362276 PMCID: PMC7757900 DOI: 10.1371/journal.pone.0243838] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/29/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known of nosocomial infections (NI) in patients who suffer from in-hospital cardiac arrest who undergoing extracorporeal cardiopulmonary resuscitation. This study aimed to investigate clinical pictures of NI, and the association of NIs with clinical outcomes in in-hospital cardiac arrest patients who undergoing extracorporeal cardiopulmonary resuscitation. METHODS To evaluate the incidence and clinical characteristics of NI in patients who undergoing extracorporeal cardiopulmonary resuscitation, a retrospective cohort study was conducted in a single tertiary referral center between January 2010 and December 2018. We included adult patients who undergoing extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest and excluded patients who were out-of-hospital cardiac arrest or failed ECMO implantation. Clinical characteristics and outcomes were compared between NI and Non-NI patients, or multidrug-resistant (MDR) and non-MDR. The independent risk factors associated with NIs were also analyzed using multivariable logistic regression model. RESULTS Thirty-five (23.3%) patients developed a NI. These cases included 21 patients with a gram negative (G-) infection, 12 patients with a gram positive (G+) bacterial infection, and two patients with fungal infection. Pneumonia was the most common type of NIs, followed by catheter-related infection. The in-hospital mortality and neurologic outcomes at discharge were not different between the NI and non-NI groups. Multidrug-resistant (MDR) pathogens were detected in 10 cases (28.6%). The MDR NI patients had a higher ICU mortality than did those with non-MDR NI (80% vs. 32%, p = 0.028). Following multivariable adjustment, body mass index (adjusted OR 0.87, 95% CI, 0.77-0.97, p = 0.016) and cardiopulmonary resuscitation to pump on time (adjusted OR 1.04, 95% CI, 1.01-1.06, p = 0.001) were independent predictors of NI development. CONCLUSIONS In patients who received extracorporeal cardiopulmonary resuscitation, NIs were not associated with an increase in in-hospital mortality. However, NIs with MDR organisms do increase the risk of in-hospital mortality. Lower body mass index and longer low flow time were significant predictors of NI development.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, 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, Korea
| | - Gee Young Suh
- 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, Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Hospital-Acquired Infection in Pediatric Subjects With Congenital Heart Disease Postcardiotomy Supported on Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:e1020-e1025. [PMID: 32590829 DOI: 10.1097/pcc.0000000000002409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine prevalence of and risk factors for infection in pediatric subjects with congenital heart disease status postcardiotomy supported on extracorporeal membrane oxygenation, as well as outcomes of these subjects. DESIGN Retrospective cohort from the Extracorporeal Life Support Organization. SETTING U.S. and international medical centers providing care to children with congenital heart disease status postcardiotomy. PATIENTS Critically ill pediatric subjects less than 8 years old admitted to medical centers between January 1, 2013, and December 31, 2015, who underwent cardiac surgery for congenital heart disease and required extracorporeal membrane oxygenation support within the first 14 postoperative days. Subjects were excluded if they underwent orthotopic heart transplantation, required preoperative extracorporeal membrane oxygenation, and had more than one postoperative extracorporeal membrane oxygenation run. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,314 extracorporeal membrane oxygenation subject encounters in the Extracorporeal Life Support Organization registry met inclusion criteria. Neonates comprised 53% (n = 696) of the cohort, whereas infants made up 33% (n = 435). Of the 994 subjects with Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categorizable surgery, 33% (n = 325) were in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 23% (n = 231) in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 5. While on extracorporeal membrane oxygenation, 229 subjects (17%) acquired one or more extracorporeal membrane oxygenation-related infections, which represents an occurrence rate of 67 infections per 1,000 extracorporeal membrane oxygenation days. Gram-negative (62%) and Gram-positive (42%) infections occurred most commonly. Forty percent had positive blood cultures. Infants and children were at higher infection risk compared with neonatal subjects; subjects undergoing less complex surgery had higher infection rates. Unadjusted survival to hospital discharge was lower in infected subjects compared with noninfected subjects (43% vs 51%; p = 0.01). After adjusting for confounders via propensity matching, we identified no significant mortality difference between infected and noninfected subjects. CONCLUSIONS Neonatal and pediatric subjects in this study have a high rate of acquired infection. Infants and children were at higher infection risk compared with neonatal subjects. There was not, however, a significant association between extracorporeal membrane oxygenation-related infection and survival to hospital discharge after propensity matching.
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Abstract
We retrospectively reviewed all pertinent extracorporeal membrane oxygenation (ECMO) studies (January 1995 to September 2017) of adults with sepsis as a primary indication for intervention and its association with morbidity and mortality. Collected data included study type, ECMO configuration, outcomes, effect size, and other features. Advanced age was a risk factor for death. Compared with nonsurvivors, survivors had a lower median Sepsis-Related Organ Failure Assessment score on day 3 (15 vs. 18, p = 0.01). Biomarkers in survivors and nonsurvivors, respectively, were peak lactate (from two studies: 4.5 vs. 15.1 mmol/L, p = 0.03; 3.6 ± 3.7 vs. 3.3 ± 2.4 mmol/L, p = 0.850) and procalcitonin levels (41 vs. 164 ng/ml, p = 0.008). Bacteremia was associated with catheter colonization, and 90.5% of a group without bloodstream infections survived to discharge; ECMO weaning was possible for less than half the bloodstream infection group. Myocarditis portended favorable outcomes for patients with sepsis who received ECMO. Extracorporeal membrane oxygenation was used in immunosuppressed patients with refractory cardiopulmonary insufficiency from severe sepsis with successful weaning from ECMO for most patients. Overall survival varied substantially among studies (15.38-71.43%). Existing studies do not present well-defined patterns supporting use of ECMO in sepsis because of sample sizes and disparate study designs.
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Mahmoud AA, Avedissian SN, Al-Qamari A, Bohling T, Pham M, Scheetz MH. Pharmacokinetic Assessment of Pre- and Post-Oxygenator Vancomycin Concentrations in Extracorporeal Membrane Oxygenation: A Prospective Observational Study. Clin Pharmacokinet 2020; 59:1575-1587. [PMID: 32468446 DOI: 10.1007/s40262-020-00902-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary life support frequently utilized in catastrophic lung and or cardiac failure. Patients on ECMO often receive vancomycin therapy for treatment or prophylaxis against Gram-positive organisms. It is unclear if ECMO affects vancomycin pharmacokinetics, thus we modeled the pharmacokinetic behavior of vancomycin according to ECMO-specific variables. METHODS Adult patients receiving vancomycin and Veno-Arterial-ECMO between 12/1/2016 and 10/1/2017 were prospectively enrolled. Extracorporeal membrane oxygenation settings and four sets of pre- and post-oxygenator vancomycin concentrations were collected for each patient. Compartmental models were built and assessed ECMO flow rates on vancomycin clearance and potential circuit sequestration. Bayesian posterior concentrations of the pre- and post-oxygenator concentrations were obtained for each patient, and summary pharmacokinetic parameters were calculated. Simulations were performed from the final model for efficacy and toxicity predictions. RESULTS Eight patients contributed 64 serum concentrations. Patients were a median (interquartile range) age of 58.5 years (50.8-62.3) with a calculated creatinine clearance of 39 mL/min (29.5-62.5) and ECMO flow rates of 3980 mL/min (interquartile range = 3493.75-4132.5). A three-compartment model best fit the data (Bayesian: plasma pre-oxygenation R2 = 0.99, post-oxygenation R2 = 0.99). Vancomycin clearance was not impacted by ECMO flow rate (p = 0.7). Simulations demonstrated that vancomycin 1 g twice daily was rarely sufficient for minimum inhibitory concentrations > 0.5 mg/L. Doses ≥ 1.5 g twice daily often exceeded toxicity thresholds for exposure. CONCLUSIONS Extracorporeal membrane oxygenation flow rates did not influence vancomycin clearance between flow rates of 3500 and 5000 mL/min and vancomycin was not sequestered in ECMO. Common vancomycin regimens resulted in suboptimal efficacy and/or excessive toxicity. Individual therapeutic drug monitoring is recommended for patients on ECMO.
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Affiliation(s)
- Ahmed A Mahmoud
- Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron Street, Feinberg Pavilion, LC 700, Chicago, IL, 60611, USA
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, Medical Center (UNMC) for Drug Discovery, University of Nebraska, Omaha, NE, USA.,College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Abbas Al-Qamari
- Department of Anesthesiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Chicago, IL, USA
| | - Tiffany Bohling
- Department of Anesthesia-Critical Care Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Michelle Pham
- Antiviral Pharmacology Laboratory, Medical Center (UNMC) for Drug Discovery, University of Nebraska, Omaha, NE, USA.,College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marc H Scheetz
- Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron Street, Feinberg Pavilion, LC 700, Chicago, IL, 60611, USA. .,Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA. .,Pharmacometric Center of Excellence, Chicago College of Pharmacy, Midwestern University, 555, 31st St., Downers Grove, IL, 60515, USA.
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Sepsis and ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:267-274. [PMID: 32421057 PMCID: PMC7223121 DOI: 10.1007/s12055-020-00944-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 12/02/2022] Open
Abstract
Sepsis is being recognized as an important complication of extracorporeal membrane oxygenation (ECMO) and its presence is a poor prognostic marker and increases the overall mortality. The survival rate differs in the various types of cannulation techniques. Adult patients with prolonged duration of ECMO constitute the major risk population. Ventilator-associated pneumonia and bloodstream infections form the main sources of sepsis in these patients. It is important to know the most common etiological agents for sepsis in ECMO, which varies partly with the local epidemiology of the hospitals. A high index of suspicion, drawing adequate volumes for blood culture and early and timely administration of appropriate empirical antimicrobials can substantially decrease the morbidity and mortality in this high-risk population. The dosing of antimicrobials is influenced by the pharmacological variations on ECMO machine and is an important consideration. Infection control practices are of paramount importance and need to be followed meticulously to prevent sepsis in ECMO.
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Kang S, Jang JY, Hahn J, Kim D, Lee JY, Min KL, Yang S, Wi J, Chang MJ. Dose Optimization of Cefpirome Based on Population Pharmacokinetics and Target Attainment during Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother 2020; 64:e00249-20. [PMID: 32122899 PMCID: PMC7179593 DOI: 10.1128/aac.00249-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022] Open
Abstract
To obtain the optimal dosage regimen in patients receiving extracorporeal membrane oxygenation (ECMO), we developed a population pharmacokinetics model for cefpirome and performed pharmacodynamic analyses. This prospective study included 15 patients treated with cefpirome during ECMO. Blood samples were collected during ECMO (ECMO-ON) and after ECMO (ECMO-OFF) at predose and 0.5 to 1, 2 to 3, 4 to 6, 8 to 10, and 12 h after cefpirome administration. The population pharmacokinetic model was developed using nonlinear mixed effects modeling and stepwise covariate modeling. Monte Carlo simulation was used to assess the probability of target attainment (PTA) and cumulative fraction of response (CFR) according to the MIC distribution. Cefpirome pharmacokinetics were best described by a two-compartment model. Covariate analysis indicated that serum creatinine concentration (SCr) was negatively correlated with clearance, and the presence of ECMO increased clearance and the central volume of distribution. The simulations showed that patients with low SCr during ECMO-ON had lower PTA than patients with high SCr during ECMO-OFF; so, a higher dosage of cefpirome was required. Cefpirome of 2 g every 8 h for intravenous bolus injection or 2 g every 12 h for extended infusion over 4 h was recommended with normal kidney function receiving ECMO. We established a population pharmacokinetic model for cefpirome in patients with ECMO, and appropriate cefpirome dosage regimens were recommended. The impact of ECMO could be due to the change in patient status on consideration of the small population and uncertainty in covariate relationships. Dose optimization of cefpirome may improve treatment success and survival in patients receiving ECMO. (This study has been registered at ClinicalTrials.gov under identifier NCT02581280.).
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Affiliation(s)
- Soyoung Kang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon, Republic of Korea
| | - June Young Jang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Dasohm Kim
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon, Republic of Korea
| | - Jun Yeong Lee
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
| | - Kyoung Lok Min
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon, Republic of Korea
| | - Seungwon Yang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung Chang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon, Republic of Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon, Republic of Korea
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Rodríguez RX, Villarroel LA, Meza RA, Peña JI, Musalem C, Kattan J, Urzúa S. Infection profile in neonatal patients during extracorporeal membrane oxygenation. Int J Artif Organs 2020; 43:391398820911379. [PMID: 32195608 DOI: 10.1177/0391398820911379] [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: 12/16/2022]
Abstract
OBJECTIVES To describe risk factors for acquired infection during neonatal extracorporeal membrane oxygenation and to examine the predictive value of inflammatory markers in the diagnosis of infection. METHODS A retrospective study was conducted with data for patients under 30 days supported with extracorporeal membrane oxygenation from 2003 to April 2016, in a neonatal intensive care unit. RESULTS Our study included 160 neonatal patients, the average age of connection was 8.5 days and the duration of extracorporeal membrane oxygenation support was 9.7 days. The incidence of confirmed infection was 23%. Patients with confirmed infection present more frequently: vaginal delivery, lower birth weight, female sex, diagnosis of congenital diaphragmatic hernia, and longer duration of extracorporeal membrane oxygenation. When comparing the group of patients with confirmed infection and suspicion of infection, there were no significant differences in the inflammatory markers. When calculating the slope for each one, the difference in white blood cell count slope 72 h before the infection is significant; in patients with confirmed infection, the count of white blood cell increases (slope: 0.25), versus the group of patients with suspected infection in whom the count decreases (slope: -0.39). No differences were found in other variables. CONCLUSION Our study describes that the factors that increase the risk of infection are lower birth weight, vaginal birth, duration of extracorporeal membrane oxygenation, and a positive trend of white blood cell 72 h prior to infection/suspicion. Further studies are necessary to include or definitively rule out the use of these factors and the biomarkers as predictors of infection in neonatal patients supported with extracorporeal membrane oxygenation.
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Affiliation(s)
| | - Luis A Villarroel
- Department of Public Health, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo A Meza
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier I Peña
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Musalem
- Department of Statistics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Kattan
- Department of Neonatology, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Soledad Urzúa
- Department of Neonatology, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
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Nosocomial Infections During Extracorporeal Membrane Oxygenation in Neonatal, Pediatric, and Adult Patients: A Comprehensive Narrative Review. Pediatr Crit Care Med 2020; 21:283-290. [PMID: 31688809 DOI: 10.1097/pcc.0000000000002190] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is increasingly used in critically ill patients with refractory cardiopulmonary failure. Nosocomial infection acquired during extracorporeal membrane oxygenation represents one of the most frequent complications but the available evidence on the risk of infection and its association with outcomes has not been comprehensively analyzed. We performed a narrative review examining the epidemiology of nosocomial infection during extracorporeal membrane oxygenation, association with clinical outcomes, and preventive strategies. DATA SOURCES We searched PubMed, Web of Science, EMBASE, and the Cochrane Library between 1972 and June 2018. STUDY SELECTION We included any article which detailed nosocomial infection during extracorporeal membrane oxygenation. Articles were excluded if they were not written in English, detailed extracorporeal membrane oxygenation use for infections acquired prior to extracorporeal membrane oxygenation, or used other forms of extracorporeal support such as ventricular assist devices. DATA EXTRACTION Two reviewers independently assessed eligibility and extracted data. We screened 984 abstracts and included 59 articles in the final review. DATA SYNTHESIS The reported risk of nosocomial infection among patients receiving extracorporeal membrane oxygenation ranged from 3.5% to 64% per extracorporeal membrane oxygenation run, while the incidence of infection ranged from 10.1 to 116.2/1,000 extracorporeal membrane oxygenation days. Nosocomial infections during extracorporeal membrane oxygenation were consistently associated with longer duration of extracorporeal membrane oxygenation and, in several large multicenter studies, with increased mortality. Risk factors for nosocomial infection included duration of extracorporeal membrane oxygenation, mechanical and hemorrhagic complications on extracorporeal membrane oxygenation, and use of venoarterial and central extracorporeal membrane oxygenation. Biomarkers had low specificity for infection in this population. Few studies examined strategies on how to prevent nosocomial infection on extracorporeal membrane oxygenation. CONCLUSIONS Nosocomial infections in extracorporeal membrane oxygenation patients are common and associated with worse outcomes. There is substantial variation in the rates of reported infection, and thus, it is possible that some may be preventable. The evidence for current diagnostic, preventive, and therapeutic strategies for infection during extracorporeal membrane oxygenation is limited and requires further investigation.
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ECLS-associated infections in adults: what we know and what we don't yet know. Intensive Care Med 2019; 46:182-191. [PMID: 31768569 PMCID: PMC7222121 DOI: 10.1007/s00134-019-05847-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/30/2019] [Indexed: 01/17/2023]
Abstract
Extracorporeal life support (ECLS) is increasingly used in the management of patients with severe cardiopulmonary disease. Infections are frequently the etiologies underlying the respiratory, and occasionally cardiac, failure that necessitates ECLS. Just as importantly, infections are among the most commonly reported adverse events during ECLS. Infections in this setting may be the sequelae of prolonged critical illness or of underlying immune dysregulation; they may be hospital-acquired infections, and they may or may not be attributable to the presence of ECLS itself, the latter being an aspect that can be difficult to determine. Current registry data and evidence from the literature offer some insights, but also leave open many questions regarding the nature and significance of infections reported both before and during ECLS, including the question of any causal link between ECLS and the development of infections. An ongoing lack of consistency in the identification, diagnosis, management, and prevention of infections during ECLS is limiting our ability to interpret literature data and thus highlighting the need for more rigorous investigation and standardization of definitions. This review aims to characterize the current understanding of infections associated with the use of ECLS, taking into account data from the updated Extracorporeal Life Support Organization Registry, which provides important context for understanding the epidemiology and outcomes of these patients.
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Extracorporeal membrane oxygenation and bloodstream infection in congenital diaphragmatic hernia. J Perinatol 2019; 39:1384-1391. [PMID: 31383944 DOI: 10.1038/s41372-019-0435-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To characterize the risk of bloodstream (BSI) and urinary tract infection (UTI) and describe antibiotic use in infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO). STUDY DESIGN The Children's Hospitals Neonatal Database was queried for infants with CDH and ECMO treatment from 2010 to 2016. The outcomes included BSI, UTI, and antimicrobial medication. Member institutions completed a survey on infection practices. RESULT Eighteen of the 338 patients identified (5.3%) had ≥1 BSI during their ECMO course. The likelihood of BSI increased with time: 1.2/1000 ECMO days; 0.6% (2/315) in the first week and rising to 14.6/1000; 8.6% (5/58) after 21 days (p = 0.002). More than 95% of patients received antibiotics each week on ECMO. CONCLUSIONS Confirmed BSI is rare in infants with CDH treated with ECMO in the first week, but increases with the duration of ECMO. Use of antibiotics was extensive and did not correspond to infection frequency.
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Lee SY, Jeon KH, Lee HJ, Kim JB, Jang HJ, Kim JS, Kim TH, Park JS, Choi RK, Choi YJ. Complications of veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock or cardiac arrest. Int J Artif Organs 2019; 43:37-44. [DOI: 10.1177/0391398819868483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: The frequency of using veno-arterial extracorporeal membrane oxygenation increased, especially in patients with refractory cardiogenic shock or cardiac arrest. However, data of complications of veno-arterial extracorporeal membrane oxygenation are lacking. This study sought to investigate the incidence of veno-arterial extracorporeal membrane oxygenation complications for acute myocardial infarction patients with refractory cardiogenic shock or cardiac arrest and its relationship with patient survival. Methods: This study included 151 consecutive patients who underwent veno-arterial extracorporeal membrane oxygenation between 2006 and 2018 at a single referral center. We divided the patients into those who survived for 30 days after veno-arterial extracorporeal membrane oxygenation ( n = 57, 38%; group 1) and those who died within 30 days after veno-arterial extracorporeal membrane oxygenation support ( n = 94, 62%; group 2). The major adverse clinical events associated with veno-arterial extracorporeal membrane oxygenation were defined as first occurrence of infection, major bleeding, and stroke. Results: Adverse clinical events associated with veno-arterial extracorporeal membrane oxygenation occurred in 34 (59.6%) and 56 (59.6%) patients in groups 1 and 2, respectively. Group 2 had more patients who underwent new renal replacement therapy (21.1% vs 37.2%, p = 0.037). After multivariable analysis, cardiac arrest was independently associated with 30-day mortality (odds ratio = 3.6; 95% confidence interval = 1.7–7.63; p = 0.001). After excluding patients who died within 48 h after undergoing veno-arterial extracorporeal membrane oxygenation, new renal replacement therapy (odds ratio = 4.47; 95% confidence interval = 1.58–12.61; p = 0.005) and major adverse clinical events (odds ratio = 2.66; 95% confidence interval = 1.01–7.03; p = 0.049) were independently associated with 30-day mortality. Conclusion: Although veno-arterial extracorporeal membrane oxygenation can improve the survival, it is associated with morbidity. Therefore, risk–benefit analysis for veno-arterial extracorporeal membrane oxygenation and prevention of complications are important to improve prognosis.
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Affiliation(s)
- Soo Youn Lee
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Ki-Hyun Jeon
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Hyun Jong Lee
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Ji-Bak Kim
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Ho-Jun Jang
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Je Sang Kim
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Tae Hoon Kim
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jin-Sik Park
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Rak Kyeong Choi
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Young Jin Choi
- Department of Cardiology, Sejong General Hospital, Bucheon, Republic of Korea
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Incidence of nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation. Heart Lung 2018; 47:626-630. [PMID: 30166066 DOI: 10.1016/j.hrtlng.2018.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/21/2018] [Accepted: 07/11/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk for developing nosocomial infections owing to their underlying disease process along with numerous invasive monitoring devices. METHODS We retrospectively analyzed the rate, type, pathogens, outcomes, and risk factors of nosocomial infections that developed during adult patients on ECMO at our institution from 2012-2015. RESULTS Compared to current ELSO reported adult nosocomial infections rate of 20.5%, we report our rate of 26% (CI 17.2%-34.7%). No significant differences were observed in mortality (42.3% vs. 36.5%; p=0.598), and presence of either antibiotics prior to ECMO (57.7% vs. 56.7%; p=0.934) or culture-proven infection prior to ECMO (19.2% vs. 32.4%; p=0.201). Patients who developed nosocomial infections had longer duration of ECMO (13 vs. 5 days; p<0.001), longer length of stay (36.5 vs. 18.5 days; p=0.004), and more days on ventilator (29 vs. 12.5; p=0.002). Duration of ECMO (OR=1.20, 95% CI 1.02-1.39; p=0.020) and duration of ECMO greater than 10 days (OR=14.65, 95% CI 1.81-118.78; p=0.012) were independent risk factors for developing nosocomial infections. However, there was no difference in mortality when duration of ECMO >10 days was compared with ≤10 days (28.5% vs. 43.1%; p=0.154). CONCLUSION Nosocomial infections have no effect on survival in adult ECMO patients. Presence of either antibiotics or infection prior to ECMO has no effect on developing nosocomial infections while on ECMO. Duration of ECMO longer than 10 days is a major risk factor for developing nosocomial infection.
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Calderón Checa RM, Rojo Conejo P, González-Posada Flores AF, Llorente de la Fuente AM, Palacios Cuesta A, Aguilar JM, Belda Hofheinz S. Experience with infections in the use of extracorporeal membrane oxygenation. An Pediatr (Barc) 2018. [DOI: 10.1016/j.anpede.2017.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Calderón Checa RM, Rojo Conejo P, González-Posada Flores AF, Llorente de la Fuente AM, Palacios Cuesta A, Aguilar JM, Belda Hofheinz S. Infecciones durante oxigenación de membrana extracorpórea. An Pediatr (Barc) 2018; 89:86-91. [DOI: 10.1016/j.anpedi.2017.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/11/2017] [Accepted: 07/15/2017] [Indexed: 11/16/2022] Open
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Cashen K, Reeder R, Dalton HJ, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Dean JM, Tamburro R, Meert KL. Acquired infection during neonatal and pediatric extracorporeal membrane oxygenation. Perfusion 2018; 33:472-482. [PMID: 29638203 DOI: 10.1177/0267659118766436] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Our objectives are to (1) describe the pathogens, site, timing and risk factors for acquired infection during neonatal and pediatric ECMO and (2) explore the association between acquired infection and mortality. METHODS Secondary analysis of prospective data collected by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014. Clinical factors associated with acquired infection were assessed with multivariable Cox regression. Factors associated with mortality were assessed with logistic regression. RESULTS Of 481 patients, 247 (51.3%) were neonates and 400 (83.2%) received venoarterial ECMO. Eighty (16.6%) patients acquired one or more infections during ECMO; 60 (12.5%) patients had bacterial, 21 (4.4%) had fungal and 11 (2.3%) had viral infections. The site of infection included respiratory for 53 (11.0%) patients, bloodstream for 21 (4.4%), urine for 20 (4.2%) and other for 7 (1.5%). Candida species were most common. Median time to infection was 5.2 days (IQR 2.3, 9.6). On multivariable analysis, a greater number of procedures for ECMO cannula placement was independently associated with increased risk of acquired infection during ECMO (Hazard Ratio 2.13 (95% CI 1.22, 3.72), p<0.01) and receiving ECMO in a neonatal ICU compared to a pediatric or cardiac ICU was associated with decreased risk (Hazard Ratio pediatric ICU 4.25 (95% CI 2.20, 8.20), cardiac ICU 2.91 (95% CI 1.48, 5.71), neonatal ICU as reference, p<0.001). Acquired infection was not independently associated with mortality. CONCLUSION ECMO procedures and location may contribute to acquired infection risk; however, acquired infection did not predict mortality in this study.
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Affiliation(s)
- Katherine Cashen
- 1 Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
| | - Ron Reeder
- 2 Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Heidi J Dalton
- 3 Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Robert A Berg
- 4 Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas P Shanley
- 5 Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago/Northwestern University Feinberg School of Medicine; Chicago, IL, USA
| | - Christopher J L Newth
- 6 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- 7 Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - David Wessel
- 7 Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Joseph Carcillo
- 8 Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Rick Harrison
- 9 Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - J Michael Dean
- 2 Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert Tamburro
- 10 Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Kathleen L Meert
- 1 Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
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Santiago-Lozano MJ, Barquín-Conde ML, Fuentes-Moreno L, León-Vela RM, Madrid-Vázquez L, Sánchez-Galindo A, López-Herce Cid J. Infectious complications in paediatric patients treated with extracorporeal membrane oxygenation. Enferm Infecc Microbiol Clin 2017; 36:563-567. [PMID: 29203305 DOI: 10.1016/j.eimc.2017.10.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The aim of this study was to analyse the incidence, treatment and evolution of infections in children treated with ECMO. METHODS A retrospective study based on a prospective database was performed. Children under the age of 18 years treated with ECMO from September 2006 to November 2015 were included. The patients' clinical characteristics were collected, together with ECMO technique, cultures and treatment of infection. RESULTS One hundred patients with a median age of 11 months were analysed. Heart disease was diagnosed in 94 patients. An infection was suspected and antibiotic treatment was initiated in 51 patients, although only 22 of them were microbiologically confirmed. The most common infection was sepsis (49%), followed by pneumonia (35.3%) and urinary tract infection (9.8%). There were no differences in haematological parameters and acute phase reactants between children with infection and those without. Children who died had a higher incidence of infection during ECMO (60.4%) than the survivors (40.3%), but the difference did not reach statistical significance (P=.07). The duration of admission in the PICU was 57 days in patients with infection vs 37 days in patients without infection but the difference was not statistically significant (P=.067). CONCLUSIONS Infection in children with ECMO is common. There are no specific infection parameters and less than half of the clinical infections are confirmed microbiologically. There was no statistically significant correlation between infection and mortality or duration of PICU stay.
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Affiliation(s)
- Maria José Santiago-Lozano
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007
| | | | - Lucía Fuentes-Moreno
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Roberto Manuel León-Vela
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Lucas Madrid-Vázquez
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Amelia Sánchez-Galindo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007
| | - Jesús López-Herce Cid
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007; Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España.
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Sun G, Li B, Lan H, Wang J, Lu L, Feng X, Luo X, Yan H, Mu Y. Factores de riesgo de las infecciones nosocomiales en pacientes que reciben oxigenación por membrana extracorpórea. Med Clin (Barc) 2017. [DOI: 10.1016/j.medcli.2017.03.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nosocomial Infections During Extracorporeal Membrane Oxygenation: Incidence, Etiology, and Impact on Patients' Outcome. Crit Care Med 2017; 45:1726-1733. [PMID: 28777198 DOI: 10.1097/ccm.0000000000002652] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To study incidence, type, etiology, risk factors, and impact on outcome of nosocomial infections during extracorporeal membrane oxygenation. DESIGN Retrospective analysis of prospectively collected data. SETTING Italian tertiary referral center medical-surgical ICU. PATIENTS One hundred five consecutive patients who were treated with extracorporeal membrane oxygenation from January 2010 to November 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ninety-two patients were included in the analysis (48.5 [37-56] years old, simplified acute physiology score II 37 [32-47]) who underwent peripheral extracorporeal membrane oxygenation (87% veno-venous) for medical indications (78% acute respiratory distress syndrome). Fifty-two patients (55%) were infected (50.4 infections/1,000 person-days of extracorporeal membrane oxygenation). We identified 32 ventilator-associated pneumonia, eight urinary tract infections, five blood stream infections, three catheter-related blood stream infections, two colitis, one extracorporeal membrane oxygenation cannula infection, and one pulmonary-catheter infection. G+ infections (35%) occurred earlier compared with G- (48%) (4 [2-10] vs. 13 [7-23] days from extracorporeal membrane oxygenation initiation; p < 0.001). Multidrug-resistant organisms caused 56% of bacterial infections. Younger age (2-35 years old) was independently associated with higher risk for nosocomial infections. Twenty-nine patients (31.5%) died (13.0 deaths/1,000 person-days of extracorporeal membrane oxygenation). Infected patients had higher risk for death (18 vs. 8 deaths/1,000 person-days of extracorporeal membrane oxygenation; p = 0.037) and longer ICU stay (32.5 [19.5-78] vs. 19 [10.5-27.5] days; p = 0.003), mechanical ventilation (36.5 [20-80.5] vs. 16.5 [9-25.5] days; p < 0.001), and extracorporeal membrane oxygenation (25.5 [10.75-54] vs. 10 [5-13] days; p < 0.001). Older age (> 50 years old), reason for connection different from acute respiratory distress syndrome, higher simplified acute physiology score II, diagnosis of ventilator-associated pneumonia, and infection by multidrug-resistant bacteria were independently associated to increased death rate. CONCLUSIONS Infections (especially ventilator-associated pneumonia) during extracorporeal membrane oxygenation therapy are common and frequently involve multidrug-resistant organisms. In addition, they have a negative impact on patients' outcomes.
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Biffi S, Di Bella S, Scaravilli V, Peri AM, Grasselli G, Alagna L, Pesenti A, Gori A. Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention. Int J Antimicrob Agents 2017; 50:9-16. [DOI: 10.1016/j.ijantimicag.2017.02.025] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 11/27/2022]
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