1
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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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2
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Challener DW, Gao X, Tehranian S, Kashani KB, O'Horo JC. Body temperature and infection in critically ill patients on continuous kidney replacement therapy. BMC Nephrol 2023; 24:161. [PMID: 37286960 DOI: 10.1186/s12882-023-03225-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 05/31/2023] [Indexed: 06/09/2023] Open
Abstract
PURPOSE Continuous kidney replacement therapy (CKRT) is an increasingly common intervention for critically ill patients with kidney failure. Because CKRT affects body temperature, detecting infections in patients on CKRT is challenging. Understanding the relation between CKRT and body temperature may facilitate earlier detection of infection. METHODS We retrospectively reviewed adult patients (≥ 18 years) admitted to the intensive care unit at Mayo Clinic in Rochester, Minnesota, from December 1, 2006, through November 31, 2015, who required CKRT. We summarized central body temperatures for these patients according to the presence or absence of infection. RESULTS We identified 587 patients who underwent CKRT during the study period, of whom 365 had infections, and 222 did not have infections. We observed no statistically significant differences in minimum (P = .70), maximum (P = .22), or mean (P = .55) central body temperature for patients on CKRT with infection vs. those without infection. While not on CKRT (before CKRT initiation and after cessation), all three body temperature measurements were significantly higher in patients with infection than in those without infection (all P < .02). CONCLUSION Body temperature is insufficient to indicate an infection in critically ill patients on CKRT. Clinicians should remain watchful for other signs, symptoms, and indications of infection in patients on CKRT because of expected high infection rates.
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Affiliation(s)
- Douglas W Challener
- Division of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Xiaolan Gao
- Division of Nephrology and Hypertension, Mayo Clinic, MN, Rochester, USA
| | - Shahrzad Tehranian
- Division of Nephrology and Hypertension, Mayo Clinic, MN, Rochester, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, MN, Rochester, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - John C O'Horo
- Division of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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3
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Body temperature trends of critically Ill patients on continuous renal replacement therapy: A single-center retrospective study. Am J Med Sci 2022; 364:404-408. [PMID: 35460642 DOI: 10.1016/j.amjms.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 01/15/2022] [Accepted: 03/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Interpretation of human body temperature in patients on continuous renal replacement therapy (CRRT) is challenging. Clinicians currently use definitions of 'normal' temperature derived from healthy patients over a century ago and apply these definitions to patients on continuous renal replacement therapy (CRRT). There is a significant opportunity to refine temperature definitions to apply to the increasing population of critically ill patients on CRRT. METHODS A total of 1361 critically ill patients admitted to the hospital between 12/1/2006 and 11/31/2015 and requiring CRRT were studied. Temperature data were summarized (median, IQR) and compared during time periods that patients were on CRRT and time periods that they were not on CRRT using paired comparisons. Additionally, analyses were performed to compare temperature dynamics between patients who died during their hospitalization with those who did not. RESULTS The median body temperature change was -0.6 °C (95% CI -1.3, -0.6) from 12 h before CRRT to 12 h after CRRT (p < .001), and an increase of 0.6 °C (95% CI 0.2, 0.6) from 12 h before CRRT end to 12 h after CRRT end (p < .001). Temperature significantly increased by a median 0.3 °C from the start to the end of CRRT. CONCLUSIONS There are significant body temperature changes in critically ill patients on CRRT with cooling at the time of CRRT initiation and warming at the time of CRRT cessation.
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Gu Q, Peng W, Zhu Y, Xi S, Diao M, Hu W, Zeng X. Clinical Characteristics of 10 Pregnant and Postpartum Women With Extracorporeal Membrane Oxygenation: A Retrospective Study. Front Med (Lausanne) 2022; 8:778889. [PMID: 35047527 PMCID: PMC8761626 DOI: 10.3389/fmed.2021.778889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The aim of study was to summarize the clinical characteristics and experience of extracorporeal membrane oxygenation (ECMO) in pregnant and postpartum patients. Methods and Results: We retrospectively reviewed 131 consecutive ECMO patients at our center from May 2015 to May 2021. A total of 10 Chinese patients were pregnant or postpartum at the time of ECMO initiation. Patients ranged in age from 25 to 36 years (median age 30.5 years). The ECMO duration ranged from 3 to 31 days (median duration 8 days). There was a stabilizing trend of acid-base balance and decreasing lactic acid over the 3 days following ECMO initiation. Seven (70%) patients survived at least 48 h after weaning from ECMO. Four (40%) patients survived until discharge, and four (40%) fetuses survived until discharge. Conclusion: ECMO provides a suitable temporary cardiopulmonary support for pregnant and postpartum patients. ECMO shows a favorable effect on short-term stability in critical obstetric patients.
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Affiliation(s)
- Qiao Gu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weihua Peng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Zhu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengyuan Diao
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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5
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Li Y, Xu R, Cao CS, Huang L. The successful use of extracorporeal membrane oxygenation combined with continuous renal replacement therapy for a cardiac arrest patient with refractory hypokalemia and diabetic ketoacidosis. World J Emerg Med 2022; 13:337-340. [PMID: 35837568 PMCID: PMC9233963 DOI: 10.5847/wjem.j.1920-8642.2022.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/12/2022] [Indexed: 12/10/2023] Open
Affiliation(s)
- Yang Li
- Department of Emergency Medicine, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Rui Xu
- Department of Emergency Medicine, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Chun-Shui Cao
- Department of Emergency Medicine, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Liang Huang
- Department of Emergency Medicine, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
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6
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Weyand AC, Barbaro RP, Walkovich KJ, Frame DG. Adjustments to pharmacologic therapies for hemophagocytic lymphohistiocytosis while on extracorporeal support. Pediatr Blood Cancer 2021; 68:e29007. [PMID: 33751818 PMCID: PMC8068609 DOI: 10.1002/pbc.29007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/01/2021] [Accepted: 02/23/2021] [Indexed: 11/08/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune dysregulatory syndrome characterized by severe inflammation and end-organ damage. Due to significant organ dysfunction, patients often require extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). In this report, we describe consideration for adjusting treatment in the context of extracorporeal organ support. We describe agents commonly used and dosing adjustments made in light of extracorporeal organ support. We report six cases that illustrate the feasibility of initiating standard HLH therapies in patients requiring these modalities.
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Affiliation(s)
- Angela C. Weyand
- Department of Pediatrics, Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Ryan P. Barbaro
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI
| | - Kelly J. Walkovich
- Department of Pediatrics, Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - David G. Frame
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
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7
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Effect of CRRT combined with low-flow ECMO on canines with ARDS and hypercapnia. J Artif Organs 2021; 24:336-342. [PMID: 33687574 DOI: 10.1007/s10047-021-01253-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
To observe the effect of continuous renal replacement therapy (CRRT) combined with low-flow extracorporeal membrane oxygenation (ECMO) of V-V mode on anti-inflammation, improving oxygenation and reducing PaCO2 in canines with acute respiratory distress syndrome (ARDS) and hypercapnia. A total of 30 healthy adult canines were randomly divided into sham group (n = 10), ECMO (EC) group (n = 10) and CRRT + ECMO (CR + EC) group (n = 10). Sham group was only treated with invasive mechanical ventilation. EC group was also treated with ECMO. CR + EC group was treated with CRRT combined with low-flow ECMO of V-V mode besides invasive mechanical ventilation. The results showed that hazard ratio was lower in the CR + EC group. Inflammatory factors, OI values, and PaCO2 levels were lower in the CR + EC group. There was no significant difference in the levels of MAP, CO and T among the three groups. No significant complications or death was developed in the three groups. Compared with ECMO group at T3, T6 and T9, IL-6 [(276.13 ± 8.32, 262.04 ± 7.15, 259.33 ± 7.31)ng/L VS (352.67 ± 19.24, 360.24 ± 23.58, 362.21 ± 25.24)ng/L] and TNF-α [(50.14 ± 1.75, 50.45 ± 1.81, 48.03 ± 1.24) ng/L VS (70.25 ± 3.02, 72.45 ± 3.25, 76.69 ± 2.18)ng/L] in CR + EC group were decreased (P < 0.0001). Compared with sham group, IL-6 [(343.76 ± 21.97, 345.91 ± 19.89, 340.34 ± 22.17)ng/L]and TNF-α [(68.10 ± 2.96, 67.31 ± 3.01, 70.34 ± 3.35)ng/L] of T3, T6 and T9 in CR + EC group were lower (P < 0.0001). These findings indicated that CRRT combined with low-flow ECMO of V-V mode had a positive effect on anti-inflammation, oxygenation improvement and surplus blood CO2 removal in canines with ARDS and hypercapnia. These results provide a promising treatment regimen for ARDS.
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8
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Murphy HJ, Eklund MJ, Hill J, Morella K, Cahill JB, Kiger JR, Twombley KE, Annibale DJ. Early continuous renal replacement therapy during infant extracorporeal life support is associated with decreased lung opacification. J Artif Organs 2019; 22:286-293. [PMID: 31342287 DOI: 10.1007/s10047-019-01119-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/10/2019] [Indexed: 01/16/2023]
Abstract
Lung opacification on chest radiography (CXR) is common during extracorporeal life support (ECLS), often resulting from pulmonary edema or inflammation. Concurrent use of continuous renal replacement therapy (CRRT) during ECLS is associated with improved fluid balance and cytokine filtration; through modification of these pathologic states, CRRT may modulate lung opacification observed on CXRs. We hypothesize that early CRRT use during infant ECLS decreases lung opacification on CXR. We conducted a retrospective cohort study comparing CXRs from infants receiving ECLS and early CRRT (n = 7) to matched infants who received ECLS alone (n = 7). The CXR obtained prior to ECLS, all CXRs obtained within the first 72 h of ECLS, and daily CXRs for the remainder of the ECLS course were analyzed. The outcome measure was the degree of opacification, determined by independent assessment of two, blinded pediatric radiologists using a modified Edwards et al.'s lung opacification scoring system (from Score 0: no opacification to Score 5: complete opacification). 220 CXRs were assessed (cases: 93, controls: 127). Inter-rater reliability was established (Cohen's weighted к = 0.74; p < 0.0001, good agreement). At baseline, the mean opacification score difference between cases and controls was 1 point (cases: 1.8, controls 2.8; p = 0.049). Using mixed modeling analysis for repeated measures accounting for differences at baseline, the average overall opacification score was 1.2 points lower in cases than controls (cases: 2.1, controls: 3.3; p < 0.0001). The overall distribution of scores was lower in cases than controls. Early CRRT utilization during infant ECLS was associated with decreased lung opacification on CXR.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA. .,Division of Neonatology, Medical University of South Carolina, 165 Ashley Avenue, MSC 917, Charleston, South Carolina, 29425, USA.
| | - Meryle J Eklund
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jeanne Hill
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kristen Morella
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John B Cahill
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James R Kiger
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katherine E Twombley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David J Annibale
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA. .,Division of Neonatology, Medical University of South Carolina, 165 Ashley Avenue, MSC 917, Charleston, South Carolina, 29425, USA.
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9
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Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel. J Thorac Dis 2018; 10:6993-7004. [PMID: 30746245 DOI: 10.21037/jtd.2018.11.103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.
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Affiliation(s)
- Valeria Lo Coco
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | | | - Michele Pilato
- Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Gennaro Martucci
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | | | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Clinical Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland
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10
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Files MD, Portman MA, McMullan DM, Bhat AH. Left ventricular mass response to extra-corporeal life support (ECLS) in infants. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Tijssen JA, Filler G. When CRRT on ECMO Is Not Enough for Potassium Clearance: A Case Report. Can J Kidney Health Dis 2017; 4:2054358117722559. [PMID: 28856008 PMCID: PMC5570114 DOI: 10.1177/2054358117722559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 05/26/2017] [Indexed: 11/24/2022] Open
Abstract
Background: Continuous renal replacement therapy (CRRT) is an excellent method used to remove fluid and solutes. It may also reduce the systemic inflammatory response for patients on extracorporeal membrane oxygenation (ECMO) support. The objective of this report is to describe a case where CRRT in combination with ECMO was insufficient to control hyperkalemia. Methods: We report the case of an adolescent patient with refractory symptomatic hyperkalemia due to substantial rhabdomyolysis in which CRRT insufficiently cleared the patient’s excess potassium. Results: Intermittent hemodialysis (IHD) was added and proved successful. The patient was weaned off ECMO, CRRT, and IHD, and his cardiac and renal function eventually normalized. Conclusions: Two important lessons can be learned from this case report: (1) If CRRT is insufficient in achieving a desirable potassium balance, additional IHD should be considered and (2) separate IHD access should be considered to improve efficacy.
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Affiliation(s)
- Janice A Tijssen
- Department of Pediatrics, Children's Hospital, London Health Sciences Centre, University of Western Ontario, Canada
| | - Guido Filler
- Department of Pediatrics, Children's Hospital, London Health Sciences Centre, University of Western Ontario, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Canada
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12
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Wang HJ, Wang P, Li N, Wan C, Jiang CM, He JS, Wang DJ, Zhang M, Sun LY. Effects of continuous renal replacement therapy on serum cytokines, neutrophil gelatinase-associated lipocalin, and prognosis in patients with severe acute kidney injury after cardiac surgery. Oncotarget 2017; 8:10628-10636. [PMID: 27833089 PMCID: PMC5354687 DOI: 10.18632/oncotarget.13254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 09/08/2016] [Indexed: 11/25/2022] Open
Abstract
The aim of our study was to evaluate the effect of continuous renal replacement therapy (CRRT) on serum cytokines, neutrophil gelatinase-associated lipocalin (NGAL), and prognosis in patients with severe acute kidney injury (AKI) following cardiac surgery. A total number of 153 patients with severe AKI following cardiac surgery were treated with CRRT. They were divided into the survival and non-survival groups. Clinical data from these two groups before and after CRRT were recorded and analyzed. It was found that the number of impaired organs, MODS and APACHE II scores were significantly higher in the non-survival group than those in the survival group before CRRT. After CRRT, MODS and APACHE II scores decreased significantly. The post-CRRT levels of serum TNF-a and IL-6 were significantly decreased. After CRRT, serum NGAL decreased in the two groups, but the levels were higher in the non-survival group than those in the survival group. MODS and APACHE II scores could be used to evaluate the severity of AKI in patients after cardiac surgery. CRRT is an effective treatment for these patients and high levels of TNF-a, IL-6, and NGAL are associated with a poor prognosis in these patients.
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Affiliation(s)
- Heng-Jin Wang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Nanjing Drum Tower Hospital, Nanjing Medical University (Nanjing University of Chinese Medicine), Nanjing, China
| | - Pei Wang
- Nanjing Maternity and Child Health Hospital, Nanjing Medical University, Nanjing, China
| | - Nan Li
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Cheng Wan
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chun-Ming Jiang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing-Song He
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Dong-Jin Wang
- Department of Cardiac Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Miao Zhang
- Department of Nephrology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ling-Yun Sun
- Nanjing Drum Tower Hospital, Nanjing Medical University (Nanjing University of Chinese Medicine), Nanjing, China
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13
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Krawiec C, Ballinger K, Halstead ES. Intrapulmonary Percussive Ventilation as an Airway Clearance Technique during Venoarterial Extracorporeal Life Support in an Infant with Pertussis. Front Pediatr 2017; 5:99. [PMID: 28497033 PMCID: PMC5406395 DOI: 10.3389/fped.2017.00099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/13/2017] [Indexed: 12/31/2022] Open
Abstract
Initiation of extracorporeal life support (ECLS) is often followed by complete opacification of pulmonary parenchyma and volume loss. The optimal mechanical ventilator management and lung recruitment strategy of a pediatric patient requiring extracorporeal membrane oxygenation is not known. We present a case of a 4-week old infant who developed a severe pertussis infection requiring ECLS. The severity of his illness and pertussis infection-associated intraluminal bronchiole obstruction made medical management challenging. In addition to lung protection ventilator strategies and bronchoscopy, intrapulmonary percussive ventilation was initiated to facilitate lung recruitment. This was associated with precipitous incremental improvement in lung compliance and eventual liberation from venoarterial ECLS.
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Affiliation(s)
- Conrad Krawiec
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Penn State University College of Medicine, Hershey, PA, USA
| | - Ken Ballinger
- Penn State Health Respiratory Care and Pulmonary Diagnostics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - E Scott Halstead
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Penn State University College of Medicine, Hershey, PA, USA
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Zhang YL, Hu WP, Zhou LH, Wang Y, Cheng A, Shao SN, Hong LL, Chen QY. Continuous renal replacement therapy in children with multiple organ dysfunction syndrome: a case series. Int Braz J Urol 2015; 40:846-52. [PMID: 25615255 DOI: 10.1590/s1677-5538.ibju.2014.06.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 04/06/2014] [Indexed: 11/22/2022] Open
Abstract
There is a lack of definitive information regarding the precise indications, implementation, and outcomes of continuous renal replacement therapy (CRRT) for the treatment of critically ill children. Six children (three boys, three girls) aged from 3 days to 8 years, all of whom had multiple organ failure, were submitted to bedside CRRT using M60 filter membranes. Modified Port carbonate formula was used and clotting time was maintained between 20 and 30 minutes. Activated partial thromboplastin time was 1.5- to 2-fold normal. One patient discontinued treatment due to family decision. Marked improvements were seen in the remaining five patients, including normalization of blood urea nitrogen and creatinine levels, stabilization of electrolytes, and improvements in markers of organ function. Of note, one patient (a six-year-old male) underwent the treatment for 241 hours. All five patients were subsequently discharged and recovered uneventfully. CRRT is effective for the management of children who are critically ill due to multiple organ failure.
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Affiliation(s)
- Yan-lin Zhang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Wei-ping Hu
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Ling-hui Zhou
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Yin Wang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Ao Cheng
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Si-nan Shao
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Ling-Ling Hong
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Qiu-yue Chen
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
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15
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Outcome of patients on combined extracorporeal membrane oxygenation and continuous renal replacement therapy: a retrospective study. Int J Artif Organs 2015; 38:133-7. [PMID: 25656009 DOI: 10.5301/ijao.5000381] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy used in the management of cardiopulmonary failure. Continuous renal replacement therapy (CRRT) is often added to the treatment for the correction of fluid and electrolyte imbalance in patients with acute kidney injury. Most of the literature on the use of combined ECMO and CRRT has been on pediatric patients. There are limited outcome data on the use of these combined modalities in adult patients. METHODS This is a retrospective analysis of all the patients above the age of 18 years who underwent combined ECMO and CRRT at a tertiary care medical center during the period January 2007 to January 2012. The primary outcomes measured were mortality at one year and renal recovery or dialysis dependence at one month. RESULTS A total of 40 patients who were treated concurrently with ECMO and CRRT were identified. The mean age was 47.01 ± 18.29 years. The most common indications for initiation of CRRT were combined fluid overload and electrolyte imbalance. Mortality at one month was (32/40) 80%. Among the 8 survivors (20%), 3 patients required continuation of hemodialysis and 5 patients were independent of dialysis at 30 days. CONCLUSIONS Mortality of patients treated with combined ECMO and CRRT is high. Initiation of CRRT in these patients is simply an indicator of severity of illness and fatality. Younger age, higher arterial pH, left ventricular dysfunction and use of VA ECMO are associated with improved survival in these patients.
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Shinozaki K, Lampe JW, Wang CH, Yin T, Kim J, Oda S, Hirasawa H, Becker LB. Developing dual hemofiltration plus cardiopulmonary bypass in rodents. J Surg Res 2014; 195:196-203. [PMID: 25555403 DOI: 10.1016/j.jss.2014.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/14/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Emerging therapies for prolonged cardiac arrest (CA) include advanced circulatory interventions like emergency cardiopulmonary bypass (ECPB) and continuous venovenous hemofiltration (CVVHF). However, preclinical studies are limited because of the absence of a practical method of using CVVHF along with ECPB in rodents. METHODS We modified a CA model with ECPB resuscitation to include the CVVHF circuit. Adult rats were cannulated via the femoral artery or vein and the jugular vein for the ECPB circuit. A new circuit for CVVHF was added to allow ECPB and CVVHF to be started simultaneously. CVVHF blood flow at 3 mL/min could be controlled with a screw clamp during ECPB. After cessation of ECPB, the CVVHF flow was maintained using a roller pump. The filtration rate was controlled at 40 mL/h/kg in the standard volume of CVVHF and 120 mL/h/kg in the high volume (HV) of CVVHF. The driving force of hemofiltration was evaluated by monitoring transmembrane pressure and filter clearance (FCL). RESULTS Transmembrane pressure in both groups was stable for 6 h throughout CVVHF. FCL of blood urea nitrogen and potassium in the standard volume group was significantly less than the HV group (P < 0.01). FCL of blood urea nitrogen and potassium was stable throughout the CVVHF operation in both groups. CONCLUSIONS We developed a method of CVVHF along with ECPB in rodents after CA. We further demonstrated the ability to regulate both standard and HV filtration rates.
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Affiliation(s)
- Koichiro Shinozaki
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA; Department of Emergency and Critical Care Medicine, Chiba University, Chiba, Japan.
| | - Joshua W Lampe
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chih-Hsien Wang
- Division of Cardiovascular Surgery and Surgical Critical Care, Department of Surgery and Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai Yin
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Junhwan Kim
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Hirasawa
- Department of Emergency and Critical Care Medicine, Chiba University, Chiba, Japan
| | - Lance B Becker
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
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17
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Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation. Intensive Care Med 2014; 40:1256-66. [PMID: 24934814 PMCID: PMC7094895 DOI: 10.1007/s00134-014-3360-2] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/03/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess the relationship between early daily fluid balance (FB) and 90-day outcome in adult patients treated with extracorporeal membrane oxygenation (ECMO). DESIGN Retrospective observational study. SETTING Tertiary referral centre for ECMO. PATIENTS 115 patients treated with ECMO for refractory heart failure and 57 patients treated with ECMO for refractory respiratory failure. METHODS We analysed the association between early daily FB versus hospital and 90-day mortality using multivariable logistic regression model, Cox proportional-hazards model and propensity score. RESULTS We obtained detailed demographic, clinical, and biochemical data, daily FB, and continuous renal replacement days. Fifty-seven per cent of patients had acute kidney injury (AKI) at ECMO initiation, and 60 % (n = 103) of patients received continuous renal replacement therapy (CRRT) during ECMO course, beginning at a median of 1 (0-3.5) days after ECMO initiation. Overall 90-day mortality was 24 %. Survivors exhibited lower daily FB from day 3 to day 5. After adjustments, Acute Physiology and Chronic Health Evaluation (APACHE) III, CRRT during the first 3 days, major bleeding event at day 1 and positive FB on day 3 were independent predictors of 90-day mortality. Positive FB at ECMO day 3 remained an independent predictor of hospital and 90-day mortality, regardless of the statistical model used or the inclusion of a propensity score to have positive FB. CONCLUSIONS Positive FB at ECMO day 3 is an independent predictor of 90-day mortality. Further interventional studies aimed at testing the value of strategy of tight control of FB during the early ECMO period are now warranted.
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18
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He C, Yang S, Yu W, Chen Q, Shen J, Hu Y, Shi J, Wu X, Li J, Li N. Effects of continuous renal replacement therapy on intestinal mucosal barrier function during extracorporeal membrane oxygenation in a porcine model. J Cardiothorac Surg 2014; 9:72. [PMID: 24758270 PMCID: PMC4013437 DOI: 10.1186/1749-8090-9-72] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 04/07/2014] [Indexed: 12/20/2022] Open
Abstract
Backgrounds Extracorporeal membrane oxygenation (ECMO) has been recommended for treatment of acute, potentially reversible, life-threatening respiratory failure unresponsive to conventional therapy. Intestinal mucosal barrier dysfunction is one of the most critical pathophysiological disorders during ECMO. This study aimed to determine whether combination with CRRT could alleviate damage of intestinal mucosal barrier function during VV ECMO in a porcine model. Methods Twenty-four piglets were randomly divided into control(C), sham(S), ECMO(E) and ECMO + CRRT(EC) group. The animals were treated with ECMO or ECMO + CRRT for 24 hours. After the experiments, piglets were sacrificed. Jejunum, ileum and colon were harvested for morphologic examination of mucosal injury and ultrastructural distortion. Histological scoring was assessed according to Chiu’s scoring standard. Blood samples were taken from the animals at -1, 2, 6, 12 and 24 h during experiment. Blood, liver, spleen, kidney and mesenteric lymphnode were collected for bacterial culture. Serum concentrations of diamine oxidase (DAO) and intestinal fatty acid binding protein (I-FABP) were tested as markers to assess intestinal epithelial function and permeability. DAO levels were determined by spectrophotometry and I-FABP levels by enzyme linked immunosorbent assay. Results Microscopy findings showed that ECMO-induced intestinal microvillus shedding and edema, morphological distortion of tight junction between intestinal mucous epithelium and loose cell-cell junctions were significantly improved with combination of CRRT. No significance was detected on positive rate of serum bacterial culture. The elevated colonies of bacterial culture in liver and mesenteric lymphnode in E group reduced significantly in EC group (p < 0.05). Compared with E group, EC group showed significantly decreased level of serum DAO and I-FABP (p < 0.05). Conclusions CRRT can alleviate the intestinal mucosal dysfunction and bacterial translocation during VV ECMO, which may extenuate the ECMO-associated SIRS and raise the clinical effect and safety.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ning Li
- Department of General Surgery, Jinling hospital, Medical School of Nanjing University, Nanjing 210002, P,R, China.
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Lin YC, Lin YC, Lin FY, Shih CM, Wu MS, Chen TW, Chen HH, Chang NC, Tsao NW, Huang CY. Early Continuous Renal Replacement Therapy in Cardiogenic Shock Patients with Severe Acute Kidney Injury Undergoing Extracorporeal Membrane Oxygenation. Cardiorenal Med 2014. [DOI: 10.1159/000364835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Shi J, Chen Q, Yu W, Shen J, Gong J, He C, Hu Y, Zhang J, Gao T, Xi F, Li J. Continuous renal replacement therapy reduces the systemic and pulmonary inflammation induced by venovenous extracorporeal membrane oxygenation in a porcine model. Artif Organs 2013; 38:215-23. [PMID: 24329567 DOI: 10.1111/aor.12154] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary changes in veno-venous extracorporeal membrane oxygenation (VV-ECMO) are rarely determined. We compared the contribution of VV-ECMO and cannulation based on the observation of pulmonary inflammatory reaction and parenchymal construction in a porcine model of low tidal volume (VT ) ventilation. We also evaluated the effect of adding continuous renal replacement therapy (CRRT) to the ECMO circuit, because CRRT is known to reduce systemic cytokine release induced by VV-ECMO. A total of 18 pigs undergoing low-VT ventilation were randomly divided into three groups (group 1, cannulation; group 2, VV-ECMO; group 3, VV-ECMO + CRRT) and studied for 24 h. Hemodynamic and ventilation parameters were recorded. We assessed plasma and alveolar cytokines, expression of pulmonary inflammatory genes, histopathological grading, and ultrastructural changes of the lungs. During the process, inspiratory volume increased and PaO2 decreased in group 1. Systemic tumor necrosis factor-α (TNF-α) and interleukin 6 (IL-6) levels increased at 2 h in group 2 and partly decreased in group 3. At 24 h, the levels of bronchoalveolar lavage fluid, TNF-α, and IL-6 in group 2 were remarkably higher than those in groups 1 and 3. Pulmonary mRNA expression of cytokines did not differ between the groups. We observed an increased score of pulmonary pathological findings in pro-inflammatory cell infiltration and interstitial thickening of the lungs in group 2. The epithelium of the blood-air barrier after VV-ECMO was swollen. In group 3, the pulmonary parenchyma and blood-air barrier were well preserved. We concluded that in a porcine model of low-VT ventilation, both VV-ECMO and VV-ECMO in combination with CRRT provided adequate oxygenation and carbon dioxide removal. Compared with VV-ECMO alone, VV-ECMO in combination with CRRT better preserved the lung parenchyma by eliminating systemic cytokines.
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Affiliation(s)
- Jialiang Shi
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China
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Shen J, Yu W, Shi J, Chen Q, Hu Y, Zhang J, Gao T, Xi F, Gong J, He C, Li N, Li J. Effect of venovenous extracorporeal membrane oxygenation on the heart in a healthy piglet model. J Cardiothorac Surg 2013; 8:163. [PMID: 23805777 PMCID: PMC3706349 DOI: 10.1186/1749-8090-8-163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 06/07/2013] [Indexed: 12/12/2022] Open
Abstract
Background Cardiac function is important for patients treated by venovenous extracorporeal membrane oxygenation (VV ECMO), but data about the effect of VV ECMO on the heart in nonneonates is absent. We studied the effect of VV ECMO on cardiac performance, cardiomyocyte and mitochondria in an animal model. Methods Twelve farm piglets were randomly assigned into two groups: control group and ECMO group. In the ECMO group, ECMO cannulaes were placed and ECMO was instituted. Hemodynamics was recorded at baseline, 1 hour after induction, and every 4 hours thereafter, to assess the cardiac performance. All animals were monitored for 24 hours and were euthanized and myocardium was harvested. Myocardial histology, ultrastructure of cardiomyocyte and mitochondria were observed, and activities of mitochondrial complexes I-V were measured, to assess the effect to cardiomyocyte and mitochondria. Results Hemodynamics were stable in each group of animals throughout the experiment. Interstitial edema, disorderd and dissolved of focal myofilament, morphological deformations of mitochondria were observed in the ECMO group. The activities of mitochondrial complexes were decreased in the ECMO group, and complex I and IV reached significance. Conclusions VV ECMO therapy is associated with changes of ultrastructure and function of cardiomyocyte and mitochondria, inducing myocardium injury. However, the injury was mild and had no effect on the cardiac performance for healthy piglets.
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Continuous Renal Replacement Therapy (CRRT) Attenuates Myocardial Inflammation and Mitochondrial Injury Induced by Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) in a Healthy Piglet Model. Inflammation 2013; 36:1186-93. [DOI: 10.1007/s10753-013-9654-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Priddy CMO, Kajimoto M, Ledee DR, Bouchard B, Isern N, Olson AK, Des Rosiers C, Portman MA. Myocardial oxidative metabolism and protein synthesis during mechanical circulatory support by extracorporeal membrane oxygenation. Am J Physiol Heart Circ Physiol 2012. [PMID: 23203964 DOI: 10.1152/ajpheart.00672.2012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides essential mechanical circulatory support necessary for survival in infants and children with acute cardiac decompensation. However, ECMO also causes metabolic disturbances, which contribute to total body wasting and protein loss. Cardiac stunning can also occur, which prevents ECMO weaning, and contributes to high mortality. The heart may specifically undergo metabolic impairments, which influence functional recovery. We tested the hypothesis that ECMO alters oxidative metabolism and protein synthesis. We focused on the amino acid leucine and integration with myocardial protein synthesis. We used a translational immature swine model in which we assessed in heart 1) the fractional contribution of leucine (FcLeucine) and pyruvate to mitochondrial acetyl-CoA formation by nuclear magnetic resonance and 2) global protein fractional synthesis (FSR) by gas chromatography-mass spectrometry. Immature mixed breed Yorkshire male piglets (n = 22) were divided into four groups based on loading status (8 h of normal circulation or ECMO) and intracoronary infusion [(13)C(6),(15)N]-L-leucine (3.7 mM) alone or with [2-(13)C]-pyruvate (7.4 mM). ECMO decreased pulse pressure and correspondingly lowered myocardial oxygen consumption (∼40%, n = 5), indicating decreased overall mitochondrial oxidative metabolism. However, FcLeucine was maintained and myocardial protein FSR was marginally increased. Pyruvate addition decreased tissue leucine enrichment, FcLeucine, and Fc for endogenous substrates as well as protein FSR. The heart under ECMO shows reduced oxidative metabolism of substrates, including amino acids, while maintaining 1) metabolic flexibility indicated by ability to respond to pyruvate and 2) a normal or increased capacity for global protein synthesis.
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