Preliminary result of an algorithm to select proper ventricular assist devices for high-risk patients with extracorporeal membrane oxygenation support

Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future

Extracorporeal organ support (ECOS) has made remarkable progress over the last few years. Renal replacement therapy, introduced a few decades ago, was the first available application of ECOS. The subsequent evolution of ECOS enabled the enhanced support to many other organs, including the heart [veno-arterial extracorporeal membrane oxygenation (ECMO), slow continuous ultrafiltration], the lungs (veno-venous ECMO, extracorporeal carbon dioxide removal), and the liver (blood purification techniques for the detoxification of liver toxins). Moreover, additional indications of these methods, including the suppression of excessive inflammatory response occurring in severe disorders such as sepsis, coronavirus disease 2019, pancreatitis, and trauma (blood purification techniques for the removal of exotoxins, endotoxins, or cytokines), have arisen. Multiple organ support therapy is crucial since a vast majority of critically ill patients present not with a single but with multiple organ failure (MOF), whereas, traditional therapeutic approaches (mechanical ventilation for acute respiratory failure, antibiotics for sepsis, and inotropes for cardiac dysfunction) have reached the maximum efficacy and cannot be improved further. However, several issues remain to be clarified, such as the complexity and cost of ECOS systems, standardization of indications, therapeutic protocols and initiation time, choice of the patients who will benefit most from these interventions, while evidence from randomized controlled trials supporting their use is still limited. Nevertheless, these methods are currently a part of routine clinical practice in intensive care units. This editorial presents the past, present, and future considerations, as well as perspectives regarding these therapies. Our better understanding of these methods, the pathophysiology of MOF, the crosstalk between native organs resulting in MOF, and the crosstalk between native organs and artificial organ support systems when applied sequentially or simultaneously, will lead to the multiplication of their effects and the minimization of complications arising from their use.

Impella 5.0 is associated with a reduction in vasoactive support and improves hemodynamics in cardiogenic shock: A single-center experience

BACKGROUND

Treatment of cardiogenic shock (CS) often requires the use of vasopressors and inotropic agents, which are associated with an increase in mortality. Data on change in vasopressor and inotrope requirements post Impella 5.0 placement is scarce. Thus, we aimed to study the ability of Impella 5.0 to reduce these requirements.

METHODS

Retrospective analysis of consecutive patients with CS receiving Impella 5.0 was performed. Vasopressor-Inotrope Score (VIS) and a Modified Catecholamine Equivalent score (MCES) was calculated prior to and up to 72 h post-Impella implantation. Primary outcome was change in MCES from baseline to 48-h post implantation and secondary outcomes included change in VIS, changes in MCES according to SCAI Stage and to underlying etiology, and freedom from mortality at 30-days.

RESULTS

Twenty-eight patients with median age of 61 (48, 67) years were included. Impella 5.0 was associated with significant reduction in MCES from baseline [9.7 (5.3, 17)] to 48 h [5.7 (3.8, 7.5), p = 0.001]. VIS was also significantly reduced from baseline [8.3 (3.8, 19.9)] to 48 h [5.0 (2.5, 8), p = 0.003]. MCES at 48 h was significantly reduced in patients with SCAI Stage E versus Stage C (p = 0.026) and with acute myocardial infarction versus acute decompensated heart (p = 0.003). Thirty-day survival was 0% in patients that had a baseline MCES ⩾ 10 without a reduction in MCES of at least 5 at 24 h.

CONCLUSION

Impella 5.0 is associated with a significant reduction in MCES and VIS scores in patients presenting with CS with 30-day survival being dependent on MCES.

Long-Term Outcome After Venoarterial Extracorporeal Membrane Oxygenation as Bridge to Left Ventricular Assist Device Preceding Heart Transplantation

OBJECTIVES

To determine if venoarterial extracorporeal membrane oxygenation (VA ECMO) as a bridge to left ventricular assist device (LVAD) in heart transplant (HT) candidates (ie, double bridge to HT) was associated with increased morbidity and mortality when compared to LVAD bridging to HT (ie, single bridge to HT).

DESIGN

A retrospective analysis of patients undergoing LVAD support from 2011 to 2020. A Kaplan-Meier survival curve and Cox-Mantel hazard ratios (HR) were calculated during LVAD support and after HT. Postoperative complications were collected.

SETTING

University Hospital Erasme.

PARTICIPANTS

HT candidates requiring LVAD.

INTERVENTIONS

VA ECMO bridging to LVAD (ECMO-LVAD group [n = 24]) versus LVAD (LVAD group [n = 64]).

MEASUREMENTS AND MAIN RESULTS

Eighty-eight patients underwent HeartWare LVAD (HVAD, Medtronic) placement. Survival to hospital discharge and during the entire study period were lower in the ECMO-LVAD group (66.7% v 92.2%; p = 0.0027, and 37.5% v 62.5%; p = 0.035, respectively). Overall HR of death was 2.46 (95% confidence interval [CI]: 1.13-5.37; p = 0.005) in the ECMO-LVAD group and remained elevated throughout their time on LVAD support (HR 3.24 [95% CI: 1.15-9.14]; p = 0.0036). However, in patients who underwent HT (n = 50), mortality was similar between groups (HR 1.33 [95% CI: 0.33-5.31]; p = 0.66). Postoperative complications were more frequent in the ECMO-LVAD group (infection = 83.3% v 51.6%, p = 0.007; renal replacement therapy = 45.8% v 9.4%, p = 0.0001; post-LVAD ECMO = 25.0% v 1.6%; p = 0.0003).

CONCLUSIONS

VA ECMO as a bridge to LVAD support before HT was associated with increased morbidity and mortality during LVAD support. However, in patients who underwent HT, outcomes were similar regardless of VA ECMO bridging.

Association between regional economic status and renal recovery of dialysis-requiring acute kidney injury among critically ill patients

The association between regional economic status and the probability of renal recovery among patients with dialysis-requiring AKI (AKI-D) is unknown. The nationwide prospective multicenter study enrolled critically ill adult patients with AKI-D in four sampled months (October 2014, along with January, April, and July 2015) in Taiwan. The regional economic status was defined by annual disposable income per capita (ADIPC) of the cities the hospitals located. Among the 1,322 enrolled patients (67.1 ± 15.5 years, 36.2% female), 833 patients (63.1%) died, and 306 (23.1%) experienced renal recovery within 90 days following discharge. We categorized all patients into high (n = 992) and low economic status groups (n = 330) by the best cut-point of ADIPC determined by the generalized additive model plot. By using the Fine and Gray competing risk regression model with mortality as a competing risk factor, we found that the independent association between regional economic status and renal recovery persisted from model 1 (no adjustment), model 2 (adjustment to basic variables), to model 3 (adjustment to basic and clinical variables; subdistribution hazard ratio, 1.422; 95% confidence interval, 1.022–1.977; p = 0.037). In conclusion, high regional economic status was an independent factor for renal recovery among critically ill patients with AKI-D.

Prognostic factors for heart recovery in adult patients with acute fulminant myocarditis and cardiogenic shock supported with extracorporeal membrane oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an effective support method for acute fulminant myocarditis (AFM) with cardiogenic shock. However, deciding whether to bridge to a left ventricular assist device (LVAD) or to maintain ECMO support until heart recovery is still controversial.

MATERIAL AND METHODS

This was a retrospective observational study from a single center. Eighty-eight adults with AFM and ECMO support between 2006 and 2018 were included. The primary endpoint was heart recovery without heart transplantation or long-term LVAD support.

RESULTS

The heart recovery group contained 43 patients, of whom 41 were discharged after being weaned off ECMO and the other two after LVAD. Five patients with heart transplants and one with long-term LVAD support were discharged, accounting for an overall survival of 55.7%. Multivariate logistic regression revealed that peak CK-MB level, severe intraventricular conduction disturbance (asystole) and malignant arrhythmia (VT or VF) were prognostic factors for nonrecovery (P = .027 and 0.017, respectively), while early intravenous immunoglobulin (IVIG) use before ECMO was highly likely to have a protective effect with a trend toward statistical significance (P = .079). A risk score was developed: 4 points for VT/VF/asystole, 1 point for every 100 μg/L increase in the peak CK-MB level, up to a maximum of 5 points, and -3 points for early IVIG use. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.818.

CONCLUSION

High CK-MB levels and VT/VF/asystole in patients with AFM are associated with poor heart recovery. Early IVIG use shows a potentially protective effect.

Acute Kidney Injury and Septic Shock-Defined by Updated Sepsis-3 Criteria in Critically Ill Patients

Sepsis is commonly associated with acute kidney injury (AKI), particularly in those requiring dialysis (AKI-D). To date, Sepsis-3 criteria have not been applied to AKI-D patients. We investigated sepsis prevalence defined by Sepsis-3 criteria and evaluated the outcomes of septic-associated AKI-D among critically ill patients. Using the data collected from a prospective multi-center observational study, we applied the Sepsis-3 criteria to critically ill AKI-D patients treated in intensive care units (ICUs) in 30 hospitals between September 2014 and December 2015. We described the prevalence, outcomes, and characteristics of sepsis as defined by the screening Sepsis-3 criteria among AKI-D patients, and compared the outcomes of AKI-D patients with or without sepsis using the Sepsis-3 criteria. A total of 1078 patients (median 70 years; 673 (62.4%) men) with AKI-D were analyzed. The main etiology of AKI was sepsis (71.43%) and the most frequent indication for acute dialysis was oliguria (64.4%). A total of 577 (53.3% of 1078 patients) met the Sepsis-3 criteria, and 206 among the 577 patients (19.1%) had septic shock. Having sepsis and septic shock were independently associated with 90-day mortality among these ICU AKI-D patients (hazard ratio (HR) 1.23 (p = 0.027) and 1.39 (p = 0.004), respectively). Taking mortality as a competing risk factor, AKI-D patients with septic shock had a significantly reduced chance of weaning from dialysis at 90 days than those without sepsis (HR 0.65, p = 0.026). The combination of the Sepsis-3 criteria with the AKI risk score led to better performance in forecasting 90-day mortality. Sepsis affects more than 50% of ICU AKI patients requiring dialysis, and one-fifth of these patients had septic shock. In AKI-D patients, coexistent with or induced by sepsis (as screened by the Sepsis-3 criteria), there is a significantly higher mortality and reduced chance of recovering sufficient renal function, when compared to those without sepsis.

Norepinephrine Administration Is Associated with Higher Mortality in Dialysis Requiring Acute Kidney Injury Patients with Septic Shock

(1) Background: Norepinephrine (NE) is the first-line vasoactive agent used in septic shock patients; however, the effect of norepinephrine on dialysis-required septic acute kidney injury (AKI-D) patients is uncertain. (2) Methods: To evaluate the impact of NE on 90-day mortality and renal recovery in septic AKI-D patients, we enrolled patients in intensive care units from 30 hospitals in Taiwan. (3) Results: 372 patients were enrolled and were divided into norepinephrine users and non-users. After adjustment by Inverse probability of treatment weighted (IPTW), there was no significant difference of baseline comorbidities between the two groups. NE users had significantly higher 90-day mortality rate and using NE is a strong predictor of 90-day mortality in the multivariate Cox regression (HR = 1.497, p = 0.027) after adjustment. The generalized additive model disclosed norepinephrine alone exerted a dose–dependent effect on 90-day mortality, while other vasoactive agents were not. (4) Conclusion: Using norepinephrine in septic AKI-D patients is associated with higher 90-day mortality and the effect is dose-dependent. Further study to explore the potential mechanism is needed.

Perioperative body weight change is associated with in-hospital mortality in cardiac surgical patients with postoperative acute kidney injury

Background

Postoperative acute kidney injury (AKI) is common following cardiac surgery (CS). Body weight (BW) may be an amenable variable by representing the summation of the nutritional and the fluid status. However, the predictive role of perioperative BW changes in CS patients with severe postoperative AKI is never explored. This study aimed to evaluate this association.

Methods

This study was conducted using a prospectively collected multicenter cohort, NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure) database. The adult CS patients with postoperative AKI requiring renal replacement therapy (RRT), who had clear initial consciousness, received CS within 14 days of hospitalization, and underwent RRT within seven days after CS in intensive care units from January 2001 to January 2014 were enrolled. With the endpoint of 30-day postoperative mortality, we evaluated the association between the clinical factors denoting fluid status and patients outcomes.

Results

A total of 188 patients (70 female, mean age 63.7 ± 15.2 years) were enrolled. Comparing with the survivors (n = 124), the non-survivors (n = 64) had a significantly higher perioperative BW change [3.6 ± 6.1% versus 0.1 ± 8.3%, p = 0.003] but not the postoperative and pre-RRT BW changes. By using multivariate Cox proportional hazards model, the independent indicators of 30-day postoperative mortality included perioperative BW change (p = 0.026) and packed red blood cells transfusion (p = 0.007), postoperative intra-aortic balloon pump (p = 0.001) and central venous pressure level (p = 0.005), as well as heart rate (p = 0.022), sequential organ failure assessment score (p < 0.001), logistic organ dysfunction score (p = 0.001), and blood total bilirubin level (p = 0.044) at RRT initiation. The generalized additive models further demonstrated, in a multivariate manner, that the mortality risk rose significantly during a perioperative BW change of 2% to 15%.

Conclusions

Perioperative BW change was independently associated with an increased risk for 30-day postoperative mortality in CS patients with RRT-requiring AKI.

Characteristics and Outcomes of Patients Bridged to Cardiac Transplantation on Centrifugal Ventricular Assist Devices: A Case Series of the Early Experience of One Canadian Transplant Centre

BACKGROUND

Centrifugal ventricular assist devices (VADs) have been used successfully to bridge patients in cardiogenic shock to cardiac transplantation, though complications are frequent and often life-threatening.

PURPOSE

To describe characteristics and examine outcomes of patients bridged to cardiac transplantation on centrifugal VADs.

METHODS

A retrospective health record review was conducted on all adults over a 12 year period (N=20) placed on centrifugal VADs with the intent to bridge to cardiac transplantation at a major Canadian transplant centre.

RESULTS

Complications of VAD support necessitated removal of 12 patients from the transplant list; seven (35%) survived to cardiac transplantation. Of the seven recipients, five survived to discharge and four remain alive and well.

CONCLUSIONS

Bridging patients on centrifugal VADs to cardiac transplantation requires improvement, including maintaining patient stability during the period of early VAD institution, aggressively managing complications of VAD support, and consideration of long-term pulsatile devices. However, if patients survive to transplantation, good long-term outcomes are expected.

Incidence and mortality of postoperative acute kidney injury in non-dialysis patients: comparison between the AKIN and KDIGO criteria

OBJECTIVES

This retrospective study determines whether the kidney disease: improving global outcomes (KDIGO) criteria are superior to acute kidney injury network (AKIN) criteria in detecting non-dialysis AKI events and predicting mortality in chronic kidney disease (CKD) patients after surgery.

METHODS

Surgical patients who were admitted to the intensive care unit were enrolled. Non-dialysis AKI cases were defined using either KDIGO or AKIN creatinine criteria and stratified by CKD stages. The adjusted hazard ratios (AHRs) for in-hospital mortality are compared to those without AKI. The cumulative survival curves and the predictability for mortality are accessed by Kaplan-Meier method and calculating the area under the curve (AUC) for the receiver operating characteristic (ROC) curve, respectively.

RESULTS

From a total of 826 postoperative patients, the overall in-hospital mortality rate was 11.6% (96 cases) and that for AKI according to KDIGO and AKIN criteria was 30.0% (248 cases) and 31.0% (256 cases). The cumulative survival curve stratified by CKD and AKI stages were comparable between KDIGO and AKIN criteria. The discriminative power for mortality stratified by CKD stages for KDIGO and AKIN criteria are as followed: all subjects: 0.678 versus 0.670 (both ps <0.001); non-CKD: 0.800 versus 0.809 (both ps <0.001); early-stage CKD: 0.676 versus 0.676 (both ps <0.001); late-stage CKD: 0.674 versus 0.660 (ps were <0.001 and 0.003).

CONCLUSION

The KDIGO criteria are superior to AKIN criteria in predicting mortality after surgery, especially in those with advanced CKD.

The association between the duration of postoperative acute kidney injury and in-hospital mortality in critically ill patients after non-cardiac surgery: an observational cohort study

OBJECTIVES

The severity of acute kidney injury (AKI) has been a well-known predictor for in-hospital mortality. Whether AKI duration could predict in-hospital mortality is not clear. This study determines the association between the in-hospital mortality and AKI duration in patients after non-cardiac surgery.

MATERIALS AND METHODS

Surgical patients who were admitted to the ICU were enrolled. AKI cases were defined using KDIGO guidelines and categorized according to the tertiles of AKI duration (1st tertile: 2 days, 2nd tertile: 3-6 days and 3rd tertile: 7 days). The adjusted hazard ratios (HRs) for in-hospital mortality are compared to those without AKI. The predictability of mortality is accessed by calculating the area under the curve (AUC) for the receiver operating characteristic (ROC) curve.

RESULTS

From a total of 318 postoperative patients, 98 developed AKI (1st tertile: 34 cases, 2nd tertile: 30 cases and 3rd tertile: 34 cases) and 220 had no AKI. The in-hospital mortality rates are 6.8% (non-AKI), 50% (1st tertile), 46.7% (2nd tertile) and 47% (3rd tertile). The HR's for in-hospital mortality are 7.92, 6.68 and 1.68, compared to the non-AKI group (p = 0.006, 0.021 and 0.476). Cumulative in-hospital survival rates are significantly different for the non-AKI group and the AKI groups (p < 0.001). The AUC for AKI duration and stage together (0.804) is higher than that for AKI stage and AKI duration alone (0.803 and 0.777) (both ps < 0.001).

CONCLUSION

In addition to severity, the duration of AKI may be a predictor of in-hospital mortality in patients, after non-cardiac surgery.

Multi-scale symbolic entropy analysis provides prognostic prediction in patients receiving extracorporeal life support

INTRODUCTION

Extracorporeal life support (ECLS) can temporarily support cardiopulmonary function, and is occasionally used in resuscitation. Multi-scale entropy (MSE) derived from heart rate variability (HRV) is a powerful tool in outcome prediction of patients with cardiovascular diseases. Multi-scale symbolic entropy analysis (MSsE), a new method derived from MSE, mitigates the effect of arrhythmia on analysis. The objective is to evaluate the prognostic value of MSsE in patients receiving ECLS. The primary outcome is death or urgent transplantation during the index admission.

METHODS

Fifty-seven patients receiving ECLS less than 24 hours and 23 control subjects were enrolled. Digital 24-hour Holter electrocardiograms were recorded and three MSsE parameters (slope 5, Area 6-20, Area 6-40) associated with the multiscale correlation and complexity of heart beat fluctuation were calculated.

RESULTS

Patients receiving ECLS had significantly lower value of slope 5, area 6 to 20, and area 6 to 40 than control subjects. During the follow-up period, 29 patients met primary outcome. Age, slope 5, Area 6 to 20, Area 6 to 40, acute physiology and chronic health evaluation II score, multiple organ dysfunction score (MODS), logistic organ dysfunction score (LODS), and myocardial infarction history were significantly associated with primary outcome. Slope 5 showed the greatest discriminatory power. In a net reclassification improvement model, slope 5 significantly improved the predictive power of LODS; Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in MODS. In an integrated discrimination improvement model, slope 5 added significantly to the prediction power of each clinical parameter. Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in sequential organ failure assessment.

CONCLUSIONS

MSsE provides additional prognostic information in patients receiving ECLS.

Cardiovascular effects of mild hypothermia in post-cardiac arrest patients by beat-to-beat monitoring. A single centre pilot study

BACKGROUND

Data on the hemodynamic and cardiovascular effects of hypothermia in patients with cardiac arrest are scarce. The aim of this study was to evaluate the hemodynamic changes induced by hypothermia by means of Most Care(®) (pressure recording analytical method, PRAM methodology), a beat-to-beat hemodynamic monitoring method.

METHODS

We enrolled 20 patients with cardiac arrest (CA) consecutively admitted to our intensive cardiac care unit and treated with mild hypothermia (TH).

RESULTS

While non-survivors showed no changes in haemodynamic variables throughout the study period, survivors exhibited a significant increase in systemic vascular resistance indexed during hypothermia and a trend towards lower values of heart rate and higher levels of mean arterial pressure.

CONCLUSIONS

According to our data, PRAM methodology proved to be a feasible and clinically useful tool in CA patients treated with TH since it provides continuous beat-to-beat haemodynamic monitoring that is based on assessment of several haemodynamic variables. Moreover, we observed that survivors showed a different haemodynamic behaviour during hypothermia in respect to patients who died. However, further studies, performed in larger cohorts, are needed to better elucidate the haemodynamic effects of hypothermia in CA patients by means of PRAM methodology.

Continuous venovenous hemofiltration versus extended daily hemofiltration in patients with septic acute kidney injury: a retrospective cohort study

INTRODUCTION

Whether continuous venovenous hemofiltration (CVVHF) is superior to extended daily hemofiltration (EDHF) for the treatment of septic AKI is unknown. We compared the effect of CVVHF (greater than 72 hours) with EDHF (8 to 12 hours daily) on renal recovery and mortality in patients with severe sepsis or septic shock and concurrent acute kidney injury (AKI).

METHODS

A retrospective analysis of 145 septic AKI patients who underwent renal replacement therapy (RRT) between July 2009 and May 2013 was performed. These patients were treated by CVVHF or EDHF with the same polyacrylonitrile membrane and bicarbonate-based buffer. The primary outcomes measured were occurrence of renal recovery and all-cause mortality by 60 days.

RESULTS

Sixty-five and eighty patients were treated with CVVHF and EDHF, respectively. Patients in the CVVHF group had significantly higher recovery of renal function (50.77% of CVVHF group versus 32.50% in the EDHF group, P = 0.026). Median time to renal recovery was 17.26 days for CVVHF patients and 25.46 days for EDHF patients (P = 0.039). Sixty-day all-cause mortality was similar between CVVHF and EDHF groups (44.62%, and 46.25%, respectively; P = 0.844). 55.38% of patients on CVVHF and 28.75% on EDHF developed hypophosphatemia (P = 0.001). The other adverse events related to RRT did not differ between groups. On multivariate analysis, including physiologically clinical relevant variables, CVVHF therapy was significantly associated with recovery of renal function (HR 3.74; 95% CI 1.82 to 7.68; P < 0.001), but not with mortality (HR 0.69; 95% CI 0.34 to 1.41; P = 0.312).

CONCLUSIONS

Patients undergoing CVVHF therapy had significantly improved renal recovery independent of clinically relevant variables. The patients with septic AKI had similar 60-day all-cause mortality rates, regardless of type of RRT.

IL-33/ST2 pathway and classical cytokines in end-stage heart failure patients submitted to left ventricular assist device support: a paradoxic role for inflammatory mediators?

Background. Inflammation is a critical process contributing to heart failure (HF). We hypothesized that IL-33/ST2 pathway, a new mechanism regulated during cardiac stress, may be involved in the functional worsening of end-stage HF patients, candidates for left ventricular assist device (LVAD) implantation, and potentially responsible for their outcome. Methods. IL-33, ST2, and conventional cytokines (IL-6, IL-8, and TNF-α) were determined in cardiac biopsies and plasma of 22 patients submitted to LVAD implantation (pre-LVAD) and compared with (1) control stable chronic HF patients on medical therapy at the moment of heart transplantation without prior circulatory support (HT); (2) patients supported by LVAD at the moment of LVAD weaning (post-LVAD). Results. Cardiac expression of ST2/IL-33 and cytokines was lower in the pre-LVAD than in the HT group. LVAD determined an increase of inflammatory mediators comparable to levels of the HT group. Only ST2 correlated with outcome indices after LVAD implantation. Conclusions. IL-33/ST2 and traditional cytokines were involved in decline of cardiac function of ESHF patients as well as in hemodynamic recovery induced by LVAD. IL-33/ST2 pathway was also associated to severity of clinical course. Thus, a better understanding of inflammation is the key to achieving more favorable outcome by new specific therapies.

Central extracorporeal membrane oxygenation requiring pulmonary arterial venting after near-drowning

Extracorporeal membrane oxygenation (ECMO) is an effective respiratory and circulatory support in patients in refractory cardiogenic shock or cardiac arrest. Peripheral ECMO sometimes requires left heart drainage; however, few reports state that pulmonary arterial (PA) venting is required during ECMO support. We present a case of a 14-year-old boy who required PA venting during ECMO support after resuscitation from near-drowning in freshwater. A biventricular assist device with an oxygenator implantation was intended on day 1; however, we were unable to proceed because of increasing of pulmonary vascular resistance from the acute lung injury. Central ECMO with PA venting was then performed. On day 13, central ECMO was converted to biventricular assist device with an oxygenator, which was removed on day 16. This case suggests that PA venting during ECMO support may be necessary in some cases of respiratory and circulatory failure with high pulmonary vascular resistance after near-drowning.

Prevalence of acute kidney injury and prognostic significance in patients with acute myocarditis

Objective

Myocarditis is an inflammation of the myocardium. The condition is commonly associated with rapid disease progression and often results in profound shock. Impaired renal function is the result of impairment in end-organ perfusion and is highly prevalent among critically ill patients. The aim of this study was to evaluate the incidence of acute kidney injury (AKI) and identify the relationship between AKI and the prognosis of patients with acute myocarditis.

Design, Measurements and Main Results

This retrospective study reviewed the medical records of 101 patients suffering from acute myocarditis between 1996 and 2011. Sixty of these patients (59%) developed AKI within 48 hours of being hospitalized. AKI defined as AKIN stage 3 (p = 0.007) and SOFA score (p = 0.03) were identified as predictors of in-hospital mortality in multivariate analysis. The conditional effect plot of the estimated risk against SOFA score upon admission categorized according to the AKIN stages showed that the risk of in-hospital mortality was highest among patients in AKIN stage 3 with a high SOFA score.

Conclusions

Among patients with acute myocarditis, AKI defined as AKIN stage 3 and elevated SOFA score were associated with unfavorable outcomes. AKIN classification is a simple, reproducible, and easily applied evaluation tool capable of providing objective information related to the clinical prognosis of patients with acute myocarditis.

U-curve association between timing of renal replacement therapy initiation and in-hospital mortality in postoperative acute kidney injury

Background

Postoperative acute kidney injury (AKI) is associated with poor outcomes in surgical patients. This study aims to evaluate whether the timing of renal replacement therapy (RRT) initiation affects the in-hospital mortality of patients with postoperative AKI.

Methodology

This multicenter retrospective observational study, which was conducted in the intensive care units (ICUs) in a tertiary hospital (National Taiwan University Hospital) and its branch hospitals in Taiwan between January, 2002, and April, 2009, included adult patients with postoperative AKI who underwent RRT for predefined indications. The demographic data, comorbid diseases, types of surgery and RRT, and the indications for RRT were documented. Patients were categorized according to the period of time between the ICU admission and RRT initiation as the early (EG, ≦1 day), intermediate (IG, 2–3 days), and late (LG, ≧4 days) groups. The in-hospital mortality rate censored at 180 day was defined as the endpoint.

Results

Six hundred forty-eight patients (418 men, mean age 63.0±15.9 years) were enrolled, and 379 patients (58.5%) died during the hospitalization. Both the estimated probability of death and the in-hospital mortality rates of the three groups represented U-curves. According to the Cox proportional hazard method, LG (hazard ratio, 1.527; 95% confidence interval, 1.152–2.024; P = 0.003, compared with IG group), age (1.014; 1.006–1.021), diabetes (1.279; 1.022–1.601; P = 0.031), cirrhosis (2.147; 1.421–3.242), extracorporeal membrane oxygenation support (1.811; 1.391–2.359), initial neurological dysfunction (1.448; 1.107–1.894; P = 0.007), pre-RRT mean arterial pressure (0.988; 0.981–0.995), inotropic equivalent (1.006; 1.001–1.012; P = 0.013), APACHE II scores (1.055; 1.037–1.073), and sepsis (1.939; 1.536–2.449) were independent predictors of the in-hospital mortality (All P<0.001 except otherwise stated).

Conclusions

The current study found a U-curve association between the timing of the RRT initiation after the ICU admission and patients’ in-hospital mortalities, and alerts physicians of certain factors affecting the outcome after the RRT initiation.

Severity of oxidative stress and inflammatory activation in end-stage heart failure patients are unaltered after 1 month of left ventricular mechanical assistance

This study investigates the impact of early left ventricular (LV)-mechanical unloading on systemic oxidative stress and inflammation in terminal heart failure patients and their impact both on multi organ failure and on intensive care unit (ICU) stay. Circulating levels of urinary 15-isoprostane-F(2t) (8-epi-PGF2(α)) and pro-inflammatory markers [plasma interleukin (IL)-6, IL-8, and urinary neopterin, a monocyte activation index] were analyzed in 20 healthy subjects, 22 stable end-stage heart failure (ESHF) patients and in 23 LV assist device (LVAD) recipients at pre-implant and during first post-LVAD (PL) month. Multi-organ function was evaluated by total Sequential Organ Failure Assessment (tSOFA) score. In LVAD recipients the levels of oxidative-inflammatory markers and tSOFA score were higher compared to other groups. After device implantation 8-epi-PGF2(α) levels were unchanged, while IL-6, and IL-8 levels increased during first week, and at 1month returned to pre-implant values, while neopterin levels increased progressively during LVAD support. The tSOFA score worsened at 1 PL-week with respect to pre-implant value, but improved at 1 PL-month. The tSOFA score related with IL-6 and IL-8 levels, while length of ICU stay related with pre-implant IL-6 levels. These data suggest that hemodynamic instability in terminal HF is associated to worsening of systemic inflammatory and oxidative milieu that do not improve in the early phase of hemodynamic recovery and LV-unloading by LVAD, affecting multi-organ function and length of ICU stay. This data stimulate to evaluate the impact of inflammatory signals on long-term outcome of mechanical circulatory support.

Effect of diuretic use on 30-day postdialysis mortality in critically ill patients receiving acute dialysis

BACKGROUND

The impact of diuretic usage and dosage on the mortality of critically ill patients with acute kidney injury is still unclear.

METHODS AND RESULTS

In this prospective, multicenter, observational study, 572 patients with postsurgical acute kidney injury receiving hemodialysis were recruited and followed daily. Thirty-day postdialysis mortality was analyzed using Cox's proportional hazards model with time-dependent covariates. The mean age of the 572 patients was 60.8±16.6 years. Patients with lower serum creatinine (p = 0.031) and blood lactate (p = 0.033) at ICU admission, lower predialysis urine output (p = 0.001) and PaO(2)/FiO(2) (p = 0.039), as well as diabetes (p = 0.037) and heart failure (p = 0.049) were more likely to receive diuretics. A total of 280 (49.0%) patients died within 30 days after acute dialysis initiation. The analysis of 30-day postdialysis mortality by fitting propensity score-adjusted Cox's proportional hazards models with time-dependent covariates showed that higher 3-day accumulated diuretic doses after dialysis initiation (HR = 1.449, p = 0.021) could increase the hazard rate of death. Moreover, higher time-varying 3-day accumulative diuretic doses were associated with hypotension (p<0.001) and less intense hemodialysis (p<0.001) during the acute dialysis period.

BACKGROUND AND SIGNIFICANCE

Higher time-varying 3-day accumulative diuretic dose predicts mortality in postsurgical critically ill patients requiring acute dialysis. Higher diuretic doses are associated with hypotension and a lower intensity of dialysis. Caution should be employed before loop diuretics are administered to postsurgical patients during the acute dialysis period.

Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury

INTRODUCTION

Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients.

METHODS

Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT.

RESULTS

Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05).

CONCLUSIONS

Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

Survey of do-not-resuscitate orders in surgical intensive care units

BACKGROUND/PURPOSE

End-of-life decisions are always difficult and complex, especially in the surgical setting. This study examines the epidemiology of do-not-resuscitate (DNR) orders, and the clinical factors influencing DNR consent. The impact of DNR on treatment and resource use in the surgical intensive-care unit (ICU) is also assessed.

METHODS

This retrospective observational study was performed at National Taiwan University Hospital, a tertiary medical center in Taipei. A total of 14,698 patients were admitted to the surgical ICUs between January 2003 and December 2006. Of these, 13,825 (94.1%) survived to ICU discharge and 873 (5.9%) died. Of those that died, 278 (1.9% of total patients) went home to die due to terminal stage illness and 595 (4.0 % of total patients) died in the ICU. All mortality patients were included in this study.

RESULTS

Yearly DNR rates were all above 65%. The average interval from ICU admission to DNR consent remained stable at 11-13 days, but the interval from DNR consent to death increased over the study period, from 2.0 to 3.5 days. Discussion over DNR was mainly initiated by intensivists. Multivariate logistic regression analysis found that older age (odds ratio, 1.010; p = 0.017) was significantly associated with DNR consent. DNR patients had longer ICU stays, lower fraction of inspired oxygen, and less inotropic infusion, dialysis, transfusion, laboratory examination, and chest radiography, but more use of sedative drugs, analgesics, and nutrition support at the time of death. After DNR, the use of advanced antibiotics, chest radiography, laboratory examination, and transfusion decreased. Inotropic infusion, however, continued to significantly increase.

CONCLUSION

Although DNR was common in our surgical ICU patients, this request was signed late in the ICU course, when therapeutic options had been exhausted. Early initiation of DNR discussion should be promoted to improve end-of-life care and reduce futile treatments in the ICU.

A 20-year experience with urgent percutaneous cardiopulmonary bypass for salvage of potential survivors of refractory cardiovascular collapse

OBJECTIVE

In-hospital cardiac arrest or refractory shock carries a high mortality despite the use of advanced resuscitative measures. We have implemented an in-hospital, nurse-based, continuously available, percutaneous, venoarterial cardiopulmonary bypass system, also known as extracorporeal life support (ECLS), as an adjunct to resuscitation when initial measures are ineffective.

METHODS

In 1986, a system for the rapid initiation of ECLS, was created in which trained critical care nurses primed an ECLS circuit and in-house physicians percutaneously placed required cannulas. From a prospective registry, we assessed long-term survival (LTS) (> or =30 days, cardiopulmonary support weaned), short-term survival (<30 days, CPS weaned), or death on CPS.

RESULTS

One hundred fifty patients (age, 57 +/- 17 years) were urgently started on CPS for cardiac arrest (n = 127; witnessed, n = 124; unwitnessed, n = 3) and refractory shock (n = 23). Sixty-nine patients were weaned from CPS, and 81 could not be weaned. Overall, 39 (26.0%) patients achieved LTS with a subsequent Kaplan-Meier median survival of 9.5 years. Duration of CPS was 32 +/- 38 hours for LTS and 21 +/- 38 hours for non-LTS. LTS occurred in 29 (23.4%) of 124 patients started on CPS for witnessed cardiac arrest and 11 (47.8%) of 23 for refractory shock (P < .05). Among patients with CPS initiated in the cardiac catheterization laboratory, LTS was seen in 24 (50.0%) of 48 versus 15 (14.7%) of 102 in patients with CPS initiated in other locations (P < .001). Cardiopulmonary resuscitation times greater than or equal to 30 minutes were associated with lower LTS (P < .05). The most common cause of death during CPS was refractory cardiac dysfunction (39.5%), and the most common cause associated with short-term survival was neurologic/pulmonary dysfunction (53.6%). Seven patients were bridged to a left ventricular assist device, and 1 subsequently underwent heart transplantation. Multivariate analysis revealed only cardiac catheterization laboratory site of initiation as a significant independent predictor of LTS (P < .01). When dividing the 20-year experience in tertiles, recent recipients have had more common prearrest insertion. Rates of long-term survival have not changed.

CONCLUSION

Of patients started on CPS, 46% were weaned, and 26.0% were long-time survivors. Rapid initiation of CPS permits LTS for some inpatients with cardiovascular collapse when initial advanced resuscitation fails. Strategies to improve end-organ function associated with use of CPS should lead to greater LTS. This practical application of inexpensive available technology should be more widely used.

Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery

Introduction

Abdominal surgery is probably associated with more likelihood to cause acute kidney injury (AKI). The aim of this study was to evaluate whether early or late start of renal replacement therapy (RRT) defined by simplified RIFLE (sRIFLE) classification in AKI patients after major abdominal surgery will affect outcome.

Methods

A multicenter prospective observational study based on the NSARF (National Taiwan University Surgical ICU Associated Renal Failure) Study Group database. 98 patients (41 female, mean age 66.4 ± 13.9 years) who underwent acute RRT according to local indications for post-major abdominal surgery AKI between 1 January, 2002 and 31 December, 2005 were enrolled The demographic data, comorbid diseases, types of surgery and RRT, as well as the indications for RRT were documented. The patients were divided into early dialysis (sRIFLE-0 or Risk) and late dialysis (LD, sRIFLE -Injury or Failure) groups. Then we measured and recorded patients' outcome including in-hospital mortality and RRT wean-off until 30 June, 2006.

Results

The in-hospital mortality was compared as endpoint. Fifty-seven patients (58.2%) died during hospitalization. LD (hazard ratio (HR) 1.846; P = 0.027), old age (HR 2.090; P = 0.010), cardiac failure (HR 4.620; P < 0.001), pre-RRT SOFA score (HR 1.152; P < 0.001) were independent indicators for in-hospital mortality.

Conclusions

The findings of this study support earlier initiation of acute RRT, and also underscore the importance of predicting prognoses of major abdominal surgical patients with AKI by using RIFLE classification.

The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy

BACKGROUND

Particular attention should be paid to postoperative patients that suffer from severe acute kidney injury (AKI) requiring renal replacement therapy (RRT).

METHODS

This multicenter prospective observational study included 342 patients with postoperative AKI requiring RRT from January 2002 to December 2006.

RESULTS

There were 137 (40%) survivors at 90 days after the commencement of RRT. Independent predictors of 90-day mortality were older age, presence of sepsis, status post-cardiopulmonary resuscitation, necessity of continuous renal replacement therapy (CRRT), requirement of total parenteral nutrition, lower body mass index, higher Sequential Organ Failure Assessment score, and higher serum lactate level at the commencement of RRT. Further analysis among the survivors showed that lower serum creatinine at intensive care unit admission, lower Simplified Acute Physiology Score II and inotropic equivalent score at the commencement of RRT, and using CRRT were independent predictors for subsequent renal recovery.

CONCLUSIONS

The development of AKI requiring RRT in postoperative critical patients represents a substantial risk for mortality and morbidity.

Extracorporeal membrane oxygenation bridge to adult heart transplantation

Extracorporeal membrane oxygenation (ECMO) can rescue some critical patients with circulatory collapse when intra-aortic balloon pump (IABP) and ventricular assist devices (VAD) are not suitable. A subset of these patients can use ECMO for direct bridging, or indirect double bridging via VAD to heart transplantation (HTx). For these patients, we identified risk factors for unsuccessful ECMO bridging, with survival to receiving either HTx or VAD as the measure of success. The characteristics evaluated were age, sex, body mass index, pre-ECMO cardiopulmonary resuscitation (CPR), IABP use, dialysis use, sequential organ failure assessment (SOFA) score, and the etiology of cardiomyopathy. From January 1995 to August 2007, there were 70 adult ECMO patients with the intent to bridge to HTx (male: 55, age: 46 +/- 14 yr). Thirty-one patients (44%) were successful in bridging. A stepwise multivariate logistic regression analysis found that age > 50 yr (p = 0.003), pre-ECMO CPR (p = 0.001) and SOFA score > 10 at ECMO initiation (p = 0.018) were significant independent predictors of unsuccessful bridging. Direct VAD implantation, if possible, is preferable to double bridging in patients over 50 yr. Also, elective ECMO support before hemodynamic deterioration to cardiac arrest or multiple organ dysfunction would improve rates of successful ECMO bridging.

Sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for postsurgical acute renal failure

BACKGROUND

In postsurgical acute renal failure patients with moderate unstable hemodynamics or fluid overload, the choice of dialysis modality is difficult. This study was performed to compare the outcomes between the sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in these patients.

METHODS

Sequential postsurgical acute renal failure patients undergoing acute dialysis with CVVH (2002-2003), or SLED (2004-2005) as a result of severe fluid overload or moderately unstable hemodynamics were analyzed. Multivariate analyses of comorbidity, disease severity before initiating dialysis, biochemical measurements, and hemodynamic parameters for 3 days after the first dialysis session were performed by fitting multiple logistic regression models to predict patient's 30-day after hospital discharge (AHD) mortality.

RESULTS

Among the 101 recruited patients, 38 received SLED and the rest received CVVH. The 30-day AHD mortality was 62.4%. The independent risk factors of 30-day AHD mortality included older age (P = .008), lower first postdialysis mean arterial pressure (MAP) (P = .021), higher first postdialysis blood urea nitrogen level (P = .009), and absence of a history of hypertension (P = .002). A further linear regression analysis found that dialysis using SLED was associated with higher first postdialysis MAP (P = .003).

CONCLUSIONS

Among the postsurgical patients requiring acute dialysis with severe fluid overload or moderately unstable hemodynamics, the patients treated with SLED had a higher first postdialysis MAP than those treated with CVVH, which led to lower mortality. Further multicenter randomized clinical trials of larger sample size are needed to compare the effects of SLED and CVVH on the outcomes of postsurgical acute dialysis patients.

The influence of donor characteristics on survival after heart transplantation

With improved immunosuppressive regimens, transplantation techniques, and postoperative care, heart transplantation (HTx) has been established as a definite therapy for end-stage heart disease. Because of a donor shortage, we have accepted marginal individuals. In this study, we identified donor-related factors influencing survival after HTx by retrospective analysis of recipient data after primary HTx from February 2002 to December 2006. The Cox regression model was used to examine the effects of the following variables on survival of 112 heart transplant recipients: demographic data of gender, age, body weight, donor-recipient body weight ratio; history of smoking, alcohol drinking, diabetes mellitus, hypertension, hepatitis B surface antigen, anti-hepatitis C virus antibody; donor condication before transplantation including catecholamine doses, hypotension, cardiopulmonary resuscitation, creatine MB isoenzyme of creatine kinase (CK-MB), tropinin I, and cold ischemic time of the allograft. Catecholamines and smoking showed significant influences on HTx survival. In our series, the percentage of donors receiving inotropic support before donation was 88% (n = 99), and the percentage of donors with a history of smoking was 25% (n = 28). There was no influence of donor status of diabetes, hypertension, or hepatitis B or C infection on postoperative survival. Our results showed that inotropic support of and a history of smoking by the donor were significant factors influencing posttransplant survival.

Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis

BACKGROUND

Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin.

METHODS

We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18-75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00173615.

FINDINGS

Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0.0001) and a better 1-year survival than those who received conventional CPR (log rank p=0.007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0.51, 95% CI 0.35-0.74, p<0.0001), 30-day survival (HR 0.47, 95% CI 0.28-0.77, p=0.003), and 1-year survival (HR 0.53, 95% CI 0.33-0.83, p=0.006) favouring extracorporeal CPR over conventional CPR.

INTERPRETATION

Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.

Risk factors of early redialysis after weaning from postoperative acute renal replacement therapy

OBJECTIVE

The aim of this study was to identify risk factors for redialysis in postoperative patients with acute renal failure (ARF) who had previously been weaned from acute dialysis. Although recovery of renal function is anticipated in patients with ARF, no data have been reported on successful weaning from acute dialysis.

DESIGN AND SETTING

Retrospective observational case-control study in a 64-bed surgical ICU.

PATIENTS AND METHODS

Success in discontinuing dialysis was defined as cessation from dialysis for at least 30 days. A total of 304 postoperative patients who underwent acute renal replacement therapy in a surgical ICU between July 2002 and April 2005 were included. SOFA score biochemical data and renal function parameters were assessed on the day after the last session of renal replacement therapy, designated as day 0 (D0).

RESULTS

We could wean 94 patients (30.9%) from acute dialysis for more than 5 days, and 64 of these (21.1%) were successfully weaned for at least 30days. The independent predictors for resuming dialysis within 30 days were: (a) longer duration of dialysis (OR 1.06), (b) higher SOFA score on D0 (OR 1.44), (c) oliguria (urine output <100cc/8h; OR 4.17) on D1, and (d) age over 65 years (OR 6.35). The area under the ROC curve was 0.880. Two-way analysis of variance with repeated measurements over time showed a larger decline in SOFA score and an increase in urine output in patients with successful cessation of dialysis. Kaplan-Meier analysis showed a significant difference in early resumption of dialysis between patients with or without oliguria at D0.

CONCLUSIONS

More than two-thirds of patients weaned from postoperative acute dialysis for more than 5 days were free of dialysis for at least 30 days. Less urine output, longer duration of dialysis, age over 65 years, and higher disease severity score are predictive of a patient's redialysis after initial weaning from acute dialysis.

Early renal replacement therapy in patients with postoperative acute liver failure associated with acute renal failure: effect on postoperative outcomes

BACKGROUND

Acute liver failure after major surgical procedures is associated with a high risk of multiple organ failure, including acute renal failure. The optimal time to initiate renal replacement therapy for acute renal failure is controversial because of the poor overall clinical outcomes.

STUDY DESIGN

From July 2002 to January 2005, all patients who had no history of liver disease, but developed acute liver failure and subsequent renal failure requiring renal replacement therapy after major surgery, at a surgical intensive care unit, were retrospectively analyzed. Patients were divided into early or late dialysis groups based on an arbitrary blood urea nitrogen cut-off level of 80 mg/dL before renal replacement therapy.

RESULTS

Eighty consecutive patients (21 women), with a mean age of 57.8+/-17.0 (SD) years, comprised the study group. The late dialysis group (n=26) had a higher ICU mortality rate (p=0.02) and a lower renal function recovery rate (p=0.02) than the early dialysis group (n=54). Fifty-three (66.3%) patients died during their ICU stay. Independent risk factors for ICU mortality were renal replacement therapy modality (intermittent hemodialysis versus continuous venous-venous hemofiltration; odds ratio [OR]=4.32, 95% CI 1.26 to 14.79; p=0.02), predialysis APACHE II score> 20 (OR=6.52, 95% CI 1.61 to 26.36; p < 0.01), and late dialysis (OR=4.01, 95% CI 1.05 to 15.27; p=0.04).

CONCLUSIONS

The mortality rate in postoperative patients with acute liver failure-associated acute renal failure was very high. Earlier initiation of renal replacement therapy, based on the predialysis blood urea nitrogen level, with continuous venous-venous hemofiltration might provide a better ICU survival rate.

Extracorporeal Membrane Oxygenation Hybrid With Various Ventricular Assist Devices as Double Bridge to Heart Transplantation

Ventricular assist devices (VAD) have benefitted patients with end-stage heart failure as a bridge to heart transplantation (HTx). We present our experience with HTx after an extracorporeal membrane oxygenation (ECMO) hybrid with various ventricular assist devices (VAD). From May 1996 to December 2003, mechanical circulatory support with a Biopump VAD was performed in eight patients, HeartMate left VAD in eight patients, and Thoratec VAD in eight patients. Before VAD implantation, 19 patients maintained their circulation with ECMO. Half of the 24 patients were implanted with VAD to await a suitable donor for HTx. We observed that half of the patients supported by ECMO hybrid with various VAD awaited a suitable donor for HTx. In our experience, we recommend the application of ECMO for short-term support within 1 week and the Biopump VAD, Thoractec VAD, or HeartMate VAD for medium-term or long-term support as a bridge to HTx.

Outcome evaluation of the bridge-to-bridge concept in patients with cardiogenic shock

BACKGROUND

Patients with cardiogenic shock can be stabilized by percutaneous implantation of extracorporeal membrane oxygenation (ECMO). If weaning from ECMO is impossible, the implantation of a ventricular assist device (VAD) is required. Patients either go for recovery of myocardial function (bridge to recovery) or for heart transplantation (bridge to transplant).

METHODS

One hundred thirty-one patients were supported with ECMO between March 1995 and November 2005. Reasons for ECMO implantation were acute heart failure, acute or chronic heart failure, and postcardiotomy heart failure. In 28 patients, subsequent VAD implantation was necessary (bridge to bridge concept).

RESULTS

Fourteen bridge to bridge patients (50%) became long-time survivors with a mean follow-up of 39 months. Risk factors for mortality were status post-cardiopulmonary resuscitation and elevated lactate and bilirubin levels before VAD implantation. Complications after ECMO and VAD implantation were bleeding and thromboembolic events. The most common cause of death was multiorgan failure.

CONCLUSIONS

Bridge to bridge is a successful concept for selected patients with cardiogenic shock. During ECMO support, patients can be evaluated for comorbidities. For patients with a combination of risk factors (status post-cardiopulmonary resuscitation, elevated lactate levels, and impaired liver function), VAD implantation should be considered very carefully.

Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue*

OBJECTIVE

To analyze the results of acute myocardial infarction (AMI) complicated with refractory shock necessitating extracorporeal life support (ECLS) rescue and to search for associated risk factors.

DESIGN

Retrospective review of our 9-yr experience with patients initially presenting with AMI with shock necessitating ECLS rescue; analysis of patient outcomes.

SETTING

A university-affiliated tertiary referral medical center.

PATIENTS

Between 1994 and 2003 inclusively, 36 consecutive patients (age [mean +/- sd], 57 +/- 10 yrs) with AMI complicated by refractory shock and undergoing cardiopulmonary resuscitation (CPR) necessitating emergent ECLS rescue were enrolled in this study.

INTERVENTION

All patients underwent CPR before ECLS, although 30 patients (83.3%) received ECLS during CPR because spontaneous circulation failed to return. All patients underwent intraaortic counterpulsation either before or following rescue. Seven patients underwent angioplasty only, and one underwent heart transplantation without any intervention. Twenty-eight patients underwent coronary artery bypass grafting (CABG), in which the beating-heart technique was used for 20 patients.

MEASUREMENTS AND MAIN RESULTS

The pre-ECLS blood lactate level was high (13.4 +/- 8.5 mmol/L), as was the inotropic score (121.4 +/- 117.3 microg/kg/min). Twenty-five patients (69.4%) were successfully weaned off ECLS, and 12 (48%) survived to discharge (one had a neurologic deficit). The overall mortality rate was 66.7%. A lower inotropic score, reduced blood lactate level, shorter CPR duration, surgical revascularization, and a reduced total maximal Sepsis-related Organ Failure Assessment (SOFA) score were noted among survivors. Liver failure, central nervous system failure, and renal failure mainly occurred in nonsurvivors after ECLS. The technique used for surgical revascularization (beating heart or arrested heart) did not influence the outcome. ECLS is associated with a lower mortality rate than that expected (>90%) from the resultant total maximal SOFA score (16.6 +/- 3.0).

CONCLUSIONS

: AMI complicated with refractory shock remains associated with a high mortality rate, even following ECLS rescue, although ECLS might afford a better chance of survival. The SOFA score can be applied to ECLS condition as a reference point for predicting outcome.

Out-of-center extracorporeal membrane oxygenation for adult cardiogenic shock patients

Patients with cardiogenic shock refractory to conventional management require advanced mechanical circulatory support such as extracorporeal membrane oxygenation (ECMO). In hospitals lacking ECMO facilities, interhospital transportation is necessary for further patient management. Thirty-one adult cardiac patients, who were transported to our hospital by our ECMO transport team between January 1998 and July 2004, were enrolled in this study. The median transportation distance was 200 km (range: 3-300 km). During transportation, the ECMO circuit per se and the patients did not have complications. Of the 31 patients, 20 (64.2%) were weaned off ECMO or bridged to ventricular assist devices and 10 patients (32.1%) survived to discharge. Delayed transfer (>2 days) and high organ dysfunction score were associated with poor outcomes. The survival rate was similar to that of our in-hospital group (survival rate: 32.8%, n = 64). In conclusion, adult cardiogenic shock patients requiring interhospital ECMO transport had a reasonable chance of survival.