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van Galen DJM, Meinders Q, Halfwerk FR, Arens J. ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients. ASAIO J 2024; 70:377-386. [PMID: 38324706 PMCID: PMC11057491 DOI: 10.1097/mat.0000000000002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.
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Affiliation(s)
- Danny J. M. van Galen
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Quint Meinders
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Frank R. Halfwerk
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
- Department of Cardiothoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jutta Arens
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
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Beyersdorf F. Innovation and disruptive science determine the future of cardiothoracic surgery. Eur J Cardiothorac Surg 2024; 65:ezae022. [PMID: 38243711 DOI: 10.1093/ejcts/ezae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/12/2024] [Indexed: 01/21/2024] Open
Abstract
One of the currently most asked questions in the field of medicine is how any specialty in the future will evolve to ensure better health for the patients by using current, unparalleled developments in all areas of science. This article will give an overview of new and evolving strategies for cardiothoracic (CT) surgery that are available today and will become available in the future in order to achieve this goal. In the founding era of CT surgery in the 1950s and 1960s, there was tremendous excitement about innovation and disruptive science, which eventually resulted in a completely new medical specialty, i.e. CT surgery. Entirely new treatment strategies were introduced for many cardiovascular diseases that had been considered incurable until then. As expected, alternative techniques have evolved in all fields of science during the last few decades, allowing great improvements in diagnostics and treatment in all medical specialties. The future of CT surgery will be determined by an unrestricted and unconditional investment in innovation, disruptive science and our own transformation using current achievements from many other fields. From the multitude of current and future possibilities, I will highlight 4 in this review: improvements in our current techniques, bringing CT surgery to low- and middle-income countries, revolutionizing the perioperative period and treating as yet untreatable diseases. These developments will allow us a continuation of the previously unheard-of treatment possibilities provided by ingenious innovations based on the fundamentals of CT surgery.
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Affiliation(s)
- Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Germany
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3
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Saemann L, Stiller M, Willsch J, Schultze T, Matin M, Veres G, Szabó G. First experience with the new extracorporeal membrane oxygenation system Colibrì. Artif Organs 2024; 48:103-109. [PMID: 37994562 DOI: 10.1111/aor.14671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/25/2023] [Accepted: 10/12/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is increasingly used for circulatory or pulmonary support not only in-hospital but also out-of-hospital. Small dimensions and a lightweight design are important, especially for out-of-hospital use but also for intra-hospital transportation of patients who require ECMO support. We share our first experience with the new Colibrì ECMO system. PATIENTS AND METHODS From December 2022 to January 2023, we used the new Colibrì extracorporeal circulation (ECC) system in six patients with cardiac or pulmonary failure. RESULTS The Colibrì system was used in-hospital in six patients with post-cardiac surgery low output syndrome, respiratory failure due to influenza or acute respiratory distress syndrome, cardiogenic shock, pulmonary embolism, and failed weaning from cardiopulmonary bypass. The system was implanted in venovenous (VV) and venoarterial (VA) fashion in 3 patients, respectively. In one patient, the configuration was switched from VA to VV after cardiac recovery. One patient received left-ventricular unloading using the IMPELLA®5.5. ECMO run time was 1 to 13 days. We did not notice any ECC system-associated complications. No ECMO system changes were required. CONCLUSION Our case series concludes that the new Colibrì system is safe and effective for in-hospital ECMO indications. The small dimensions and lightweight design are very beneficial for the transportation of patients. It might be especially helpful for out-of-hospital situations.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
| | - Markus Stiller
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
| | - Jan Willsch
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
| | - Thomas Schultze
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
| | - Meradjoddin Matin
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
| | - Gábor Veres
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, University Hospital Halle, Halle (Saale), Germany
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Trummer G, Benk C, Pooth JS, Wengenmayer T, Supady A, Staudacher DL, Damjanovic D, Lunz D, Wiest C, Aubin H, Lichtenberg A, Dünser MW, Szasz J, Dos Reis Miranda D, van Thiel RJ, Gummert J, Kirschning T, Tigges E, Willems S, Beyersdorf F. Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study. J Clin Med 2023; 13:56. [PMID: 38202063 PMCID: PMC10780178 DOI: 10.3390/jcm13010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
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Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Jan-Steffen Pooth
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Department of Emergency Medicine, Medical Center—University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Tobias Wengenmayer
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Supady
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Dawid L. Staudacher
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center, 93042 Regensburg, Germany;
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center, 93042 Regensburg, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Dinis Dos Reis Miranda
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Robert J. van Thiel
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Thomas Kirschning
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Eike Tigges
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Stephan Willems
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
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Hsu CH, Trummer G, Belohlavek J, Yannopoulos D, Bartos JA. Wolf Creek XVII Part 7: Mechanical circulatory support. Resusc Plus 2023; 16:100493. [PMID: 37965244 PMCID: PMC10641702 DOI: 10.1016/j.resplu.2023.100493] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Introduction Failure to restore spontaneous circulation remains a major cause of death for cardiac arrest (CA) patients. Mechanical circulatory support, specifically extracorporeal cardiopulmonary resuscitation (ECPR), has emerged as a feasible and efficacious rescue strategy for selected refractory CA patients. Methods Mechanical Circulatory Support was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. Results Top 5 knowledge gaps included optimal patient selection, pre-ECPR treatments, logistical and programmatic characteristics of ECPR programs, generalizability and effectiveness of ECPR, and prevention of reperfusion injury. Top 5 barriers to translation included cost/resource limitations, technical challenges, collaboration across multiple disciplines, limited patient population, and early identification of eligible patients. Top 5 research priorities focused on comparing the outcomes of prehospital/rapid transport strategies vs in-hospital ECPR initiation, implementation of high-performing ECPR system vs standard care, rapid patient identification tools vs standard clinical judgment, post-cardiac arrest bundled care vs no bundled care, and standardized ECPR clinical protocol vs routine care. Conclusion This overview can serve as an innovative guide to transform the care and outcome of patients with refractory CA.
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Affiliation(s)
- Cindy H. Hsu
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - George Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Germany
| | - Jan Belohlavek
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Demetris Yannopoulos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Jason A. Bartos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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Damjanovic D, Pooth JS, Liu Y, Frensch F, Wolkewitz M, Haberstroh J, Doostkam S, Cristina Schmitz HR, Foerster K, Taunyane I, Neubert T, Scherer C, Diel P, Benk C, Beyersdorf F, Trummer G. The Impact of Head Position on Neurological and Histopathological Outcome Following Controlled Automated Reperfusion of the Whole Body (CARL) in a Pig Model. J Clin Med 2023; 12:7054. [PMID: 38002667 PMCID: PMC10672538 DOI: 10.3390/jcm12227054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/27/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Introduction: Based on extracorporeal circulation, targeted reperfusion strategies have been developed to improve survival and neurologic recovery in refractory cardiac arrest: Controlled Automated Reperfusion of the whoLe Body (CARL). Furthermore, animal and human cadaver studies have shown beneficial effects on cerebral pressure due to head elevation during conventional cardiopulmonary resuscitation. Our aim was to evaluate the impact of head elevation on survival, neurologic recovery and histopathologic outcome in addition to CARL in an animal model. Methods: After 20 min of ventricular fibrillation, 46 domestic pigs underwent CARL, including high, pulsatile extracorporeal blood flow, pH-stat acid-base management, priming with a colloid, mannitol and citrate, targeted oxygen, carbon dioxide and blood pressure management, rapid cooling and slow rewarming. N = 25 were head-up (HUP) during CARL, and N = 21 were supine (SUP). After weaning from ECC, the pigs were extubated and followed up in the animal care facility for up to seven days. Neuronal density was evaluated in neurohistopathology. Results: More animals in the HUP group survived and achieved a favorable neurological recovery, 21/25 (84%) versus 6/21 (29%) in the SUP group. Head positioning was an independent factor in neurologically favorable survival (p < 0.00012). Neurohistopathology showed no significant structural differences between HUP and SUP. Distinct, partly transient clinical neurologic deficits were blindness and ataxia. Conclusions: Head elevation during CARL after 20 min of cardiac arrest independently improved survival and neurologic outcome in pigs. Clinical follow-up revealed transient neurologic deficits potentially attributable to functions localized in the posterior perfusion area, whereas histopathologic findings did not show corresponding differences between the groups. A possible explanation of our findings may be venous congestion and edema as modifiable contributing factors of neurologic injury following prolonged cardiac arrest.
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Affiliation(s)
- Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Emergency Medicine, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
| | - Yechi Liu
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Fabienne Frensch
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Division Methods in Clinical Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, D-79104 Freiburg, Germany
| | - Joerg Haberstroh
- Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 66, D-79106 Freiburg, Germany
| | - Soroush Doostkam
- Institute of Neuropathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacherstr. 64, D-79106 Freiburg, Germany
| | - Heidi Ramona Cristina Schmitz
- Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 66, D-79106 Freiburg, Germany
| | - Katharina Foerster
- Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Stefan-Meier-Str. 17, D-79104 Freiburg, Germany
| | - Itumeleng Taunyane
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Tabea Neubert
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Patric Diel
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
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Pooth JS, Liu Y, Petzold R, Scherer C, Benning L, Kreibich M, Czerny M, Beyersdorf F, Benk C, Trummer G, Brixius SJ. Effects of Prolonged Serum Calcium Suppression during Extracorporeal Cardiopulmonary Resuscitation in Pigs. Biomedicines 2023; 11:2612. [PMID: 37892986 PMCID: PMC10604109 DOI: 10.3390/biomedicines11102612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023] Open
Abstract
Controlled reperfusion by monitoring the blood pressure, blood flow, and specific blood parameters during extracorporeal reperfusion after cardiac arrest has the potential to limit ischemia-reperfusion injury. The intracellular calcium overload as part of the ischemia-reperfusion injury provides the possibility for the injury to be counteracted by the early suppression of serum calcium with the aim of improving survival and the neurological outcome. We investigated the effects of prolonged serum calcium suppression via sodium citrate during extracorporeal resuscitation using the CARL protocol (CARL-controlled automated reperfusion of the whole body) compared to a single-dose approach in a porcine model after prolonged cardiac arrest. A control group (N = 10) was resuscitated after a 20 min cardiac arrest, initially lowering the intravascular calcium with the help of a single dose of sodium citrate as part of the priming solution. Animals in the intervention group (N = 13) received additional sodium citrate for the first 15 min of reperfusion. In the control group, 9/10 (90.0%) animals survived until day 7 and 7/13 (53.8%) survived in the intervention group (p = 0.09). A favorable neurological outcome on day 7 after the cardiac arrest was observed in all the surviving animals using a species-specific neurological deficit score. The coronary perfusion pressure was significantly lower with a tendency towards more cardiac arrhythmias in the intervention group. In conclusion, a prolonged reduction in serum calcium levels over the first 15 min of reperfusion after prolonged cardiac arrest tended to be unfavorable regarding survival and hemodynamic variables compared to a single-dose approach in this animal model.
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Affiliation(s)
- Jan-Steffen Pooth
- Department of Emergency Medicine, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (R.P.); (L.B.)
| | - Yechi Liu
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Ralf Petzold
- Department of Emergency Medicine, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (R.P.); (L.B.)
| | - Christian Scherer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Leo Benning
- Department of Emergency Medicine, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (R.P.); (L.B.)
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Christoph Benk
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Georg Trummer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Sam Joé Brixius
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
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Kloka JA, Friedrichson B, Wülfroth P, Henning R, Zacharowski K. Microvascular Leakage as Therapeutic Target for Ischemia and Reperfusion Injury. Cells 2023; 12:1345. [PMID: 37408180 DOI: 10.3390/cells12101345] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/03/2023] [Accepted: 05/07/2023] [Indexed: 07/07/2023] Open
Abstract
Reperfusion injury is a very common complication of various indicated therapies such as the re-opening of vessels in the myocardium or brain as well as reflow in hemodynamic shutdown (cardiac arrest, severe trauma, aortic cross-clamping). The treatment and prevention of reperfusion injury has therefore been a topic of immense interest in terms of mechanistic understanding, the exploration of interventions in animal models and in the clinical setting in major prospective studies. While a wealth of encouraging results has been obtained in the lab, the translation into clinical success has met with mixed outcomes at best. Considering the still very high medical need, progress continues to be urgently needed. Multi-target approaches rationally linking interference with pathophysiological pathways as well as a renewed focus on aspects of microvascular dysfunction, especially on the role of microvascular leakage, are likely to provide new insights.
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Affiliation(s)
- Jan Andreas Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | - Benjamin Friedrichson
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
| | | | | | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
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Pooth JS, Brixius SJ, Scherer C, Diel P, Liu Y, Taunyane IC, Damjanovic D, Wolkewitz M, Haberstroh J, Benk C, Trummer G, Beyersdorf F. Limiting calcium overload after cardiac arrest: The role of human albumin in controlled automated reperfusion of the whole body. Perfusion 2023; 38:622-630. [PMID: 35343319 DOI: 10.1177/02676591211073779] [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: 11/17/2022]
Abstract
BACKGROUND Regarding the overall inadequate results after cardiopulmonary resuscitation, the development of new treatment concepts is urgently needed. Controlled Automated Reperfusion of the whoLe body (CARL) represents a therapy bundle to control the conditions of reperfusion and the composition of the reperfusate after cardiac arrest (CA). The aim of this study was to investigate the plasma expander's role in the CARL priming solution and examine its mechanism of action. METHODS Viscosity, osmolality, colloid osmotic pressure (COP), pH and calcium binding of different priming solutions were measured in vitro and compared to in vivo data. N = 16 pigs were allocated to receive CARL following 20 min of untreated CA with either human albumin 20% (HA, N = 8) or gelatin polysuccinate 4% (GP, N = 8). Blood gas analyses were performed during the first hour of reperfusion and catecholamine and fluid requirements were recorded. Neurological outcome was assessed by neurological deficit scoring (NDS) on the seventh day. RESULTS In vitro, addition of HA to the CARL priming solution resulted in higher COP and higher calcium-binding than GP. In vivo, treatment with HA led to greater reduction of ionized calcium and higher extracorporeal flows within the first 30 min of reperfusion with no difference in catecholamine support and fluid requirement. Seven-day survival of 75% with no difference in NDS was observed in both groups. CONCLUSIONS Our data show that the plasma expander in the CARL priming solution has a significant effect on the initial reperfusate and can potentially influence the course of resuscitation. However, seven-day survival and NDS did not differ between groups.
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Affiliation(s)
- Jan-Steffen Pooth
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Sam J Brixius
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Patric Diel
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Yechi Liu
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Itumeleng C Taunyane
- Department of Cardio-Thoracic Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, 9174University of Freiburg, Freiburg, Germany
| | - Jörg Haberstroh
- Department of Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, 9202University Heart Center Freiburg, Faculty of Medicine, 9174University of Freiburg, Freiburg, Germany
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10
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Philipp A, Pooth JS, Benk C, Mueller T, Lunz D. Enabling the control of reperfusion parameters in out-of-hospital cardiac arrest: First applications of the CARL system. Perfusion 2023; 38:436-439. [PMID: 36416680 PMCID: PMC9932608 DOI: 10.1177/02676591221141325] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There is increasing evidence for extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue therapy for selected patients in refractory cardiac arrest (CA). Besides patient selection, the control of reperfusion parameters is of eminent importance. Especially in out-of-hospital CA, monitoring and individualized, targeted reperfusion remains a great challenge for emergency personnel. The CARL® system is designed to enable an early control of a variety of reperfusion parameters and to pursue a targeted reperfusion strategy in ECPR. CASE PRESENTATION We report the first 10 ECPR applications of the CARL® system in Regensburg, Germany. Early blood gas analysis, oxygen titration and pressure monitoring were feasible and enabled an individualized and targeted reperfusion strategy in all patients. After suffering from refractory CA and prolonged resuscitation attempts, five out of the first 10 patients survived and were successfully discharged from the hospital (CPC one on hospital discharge). CONCLUSION Application of the CARL® system contributed to early monitoring and control of reperfusion parameters. Whether targeted ECPR may have the potential to improve outcomes in refractory OHCA remains the subject of future investigations.
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Affiliation(s)
- Alois Philipp
- Department of Cardiothoracic
Surgery, University
Medical Center Regensburg, Regensburg,
Germany
| | - Jan-Steffen Pooth
- Department of Cardiovascular
Surgery, University
Medical Center Freiburg, Freiburg,
Germany,Faculty of Medicine,
Albert-Ludwigs-University, Freiburg,
Germany,Resuscitec
GmbH, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular
Surgery, University
Medical Center Freiburg, Freiburg,
Germany,Faculty of Medicine,
Albert-Ludwigs-University, Freiburg,
Germany,Resuscitec
GmbH, Freiburg, Germany
| | - Thomas Mueller
- Department of Internal Medicine II,
University
Medical Center Regensburg, Regensburg,
Germany
| | - Dirk Lunz
- Department of Anesthesiology,
University
Medical Center Regensburg, Regensburg,
Germany,Dirk Lunz, Department of Anesthesiology,
University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93042
Regensburg, Germany.
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11
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Bernhard P, Bretthauer BA, Brixius SJ, Bügener H, Groh JE, Scherer C, Damjanovic D, Haberstroh J, Trummer G, Benk C, Beyersdorf F, Schilling O, Pooth JS. Serum proteome alterations during conventional and extracorporeal resuscitation in pigs. J Transl Med 2022; 20:238. [PMID: 35606879 PMCID: PMC9125930 DOI: 10.1186/s12967-022-03441-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/13/2022] [Indexed: 11/26/2022] Open
Abstract
Background Only a small number of patients survive an out-of-hospital cardiac arrest (CA) and can be discharged from hospital alive with a large percentage of these patients retaining neurological impairments. In recent years, extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a beneficial strategy to optimize cardiac arrest treatment. However, ECPR is still associated with various complications. To reduce these problems, a profound understanding of the underlying mechanisms is required. This study aims to investigate the effects of CA, conventional cardiopulmonary resuscitation (CPR) and ECPR using a whole-body reperfusion protocol (controlled and automated reperfusion of the whole body—CARL) on the serum proteome profiles in a pig model of refractory CA. Methods N = 7 pigs underwent 5 min of untreated CA followed by 30 min CPR and 120 min perfusion with CARL. Blood samples for proteomic analysis were drawn at baseline, after CPR and at the end of the CARL period. Following albumin-depletion, proteomic analysis was performed using liquid chromatography–tandem mass spectrometry. Results N = 21 serum samples were measured resulting in the identification and quantification of 308–360 proteins per sample and 388 unique proteins in total. The three serum proteome profiles at the investigated time points clustered individually and segregated almost completely when considering a 90% confidence interval. Differential expression analysis showed significant abundance changes in 27 proteins between baseline and after CPR and in 9 proteins after CARL compared to CPR. Significant findings were further validated through a co-abundance cluster analysis corroborating the observed abundance changes. Conclusions The presented data highlight the impact of systemic ischemia and reperfusion on the entire serum proteome during resuscitation with a special focus on changes regarding haemolysis, coagulation, inflammation, and cell-death processes. Generally, the observed changes contribute to post-ischemic complications. Better understanding of the underlying mechanisms during CA and resuscitation may help to limit these complications and improve therapeutic options. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03441-4.
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Affiliation(s)
- Patrick Bernhard
- Institute for Surgical Pathology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Spemann Graduate School of Biology and Medicine (SGBM), University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Berit Amelie Bretthauer
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Sam Joé Brixius
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Hannah Bügener
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Johannes Elias Groh
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jörg Haberstroh
- Department of Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Oliver Schilling
- Institute for Surgical Pathology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Cardiovascular Surgery, University Heart Center Freiburg, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
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12
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Brixius SJ, Pooth JS, Haberstroh J, Damjanovic D, Scherer C, Greiner P, Benk C, Beyersdorf F, Trummer G. Beneficial Effects of Adjusted Perfusion and Defibrillation Strategies on Rhythm Control within Controlled Automated Reperfusion of the Whole Body (CARL) for Refractory Out-of-Hospital Cardiac Arrest. J Clin Med 2022; 11:jcm11082111. [PMID: 35456204 PMCID: PMC9031732 DOI: 10.3390/jcm11082111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 01/27/2023] Open
Abstract
Survival and neurological outcomes after out-of-hospital cardiac arrest (OHCA) remain low. The further development of prehospital extracorporeal resuscitation (ECPR) towards Controlled Automated Reperfusion of the Whole Body (CARL) has the potential to improve survival and outcome in these patients. In CARL therapy, pulsatile, high blood-flow reperfusion is performed combined with several modified reperfusion parameters and adjusted defibrillation strategies. We aimed to investigate whether pulsatile, high-flow reperfusion is feasible in refractory OHCA and whether the CARL approach improves heart-rhythm control during ECPR. In a reality-based porcine model of refractory OHCA, 20 pigs underwent prehospital CARL or conventional ECPR. Significantly higher pulsatile blood-flow proved to be feasible, and critical hypotension was consistently prevented via CARL. In the CARL group, spontaneous rhythm conversions were observed using a modified priming solution. Applying potassium-induced secondary cardioplegia proved to be a safe and effective method for sustained rhythm conversion. Moreover, significantly fewer defibrillation attempts were needed, and cardiac arrhythmias were reduced during reperfusion via CARL. Prehospital CARL therapy thus not only proved to be feasible after prolonged OHCA, but it turned out to be superior to conventional ECPR regarding rhythm control.
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Affiliation(s)
- Sam Joé Brixius
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
- Correspondence:
| | - Jan-Steffen Pooth
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Jörg Haberstroh
- Centre for Experimental Models and Transgenic Service, Department of Experimental Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79104 Freiburg, Germany;
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Christian Scherer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Philipp Greiner
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Christoph Benk
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Georg Trummer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
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13
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Pooth J, Trummer G, Benk C, Beyersdorf F. Important factors regarding the analysis of extracorporeal blood flow in extracorporeal cardiopulmonary resuscitation. Resuscitation 2022; 173:201-202. [DOI: 10.1016/j.resuscitation.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/30/2022]
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