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Salih F, Lambeck J, Günther A, Ferse C, Hoffmann O, Dimitriadis K, Finn A, Brandt SA, Hotter B, Masuhr F, Schreiber S, Weissinger F, Rocco A, Schneider H, Niesen WD. Brain death determination in patients with veno-arterial extracorporeal membrane oxygenation: A systematic study to address the Harlequin syndrome. J Crit Care 2024; 81:154545. [PMID: 38395004 DOI: 10.1016/j.jcrc.2024.154545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/06/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE The Harlequin syndrome may occur in patients treated with venoarterial extracorporal membrane oxygenation (VA-ECMO), in whom blood from the left ventricle and the ECMO system supply different parts of the body with different paCO2-levels. The purpose of this study was to compare two variants of paCO2-analysis to account for the Harlequin syndrome during apnea testing (AT) in brain death (BD) determination. MATERIALS AND METHODS Twenty-seven patients (median age 48 years, 26-76 years; male n = 19) with VA-ECMO treatment were included who underwent BD determination. In variant 1, simultaneous arterial blood gas (ABG) samples were drawn from the right and the left radial artery. In variant 2, simultaneous ABG samples were drawn from the right radial artery and the postoxygenator ECMO circuit. Differences in paCO2-levels were analysed for both variants. RESULTS At the start of AT, median paCO2-difference between right and left radial artery (variant 1) was 0.90 mmHg (95%-confidence intervall [CI]: 0.7-1.3 mmHg). Median paCO2-difference between right radial artery and postoxygenator ECMO circuit (variant 2) was 3.3 mmHg (95%-CI: 1.5-6.0 mmHg) and thereby significantly higher compared to variant 1 (p = 0.001). At the end of AT, paCO2-difference according to variant 1 remained unchanged with 1.1 mmHg (95%-CI: 0.9-1.8 mmHg). In contrast, paCO2-difference according to variant 2 increased to 9.9 mmHg (95%-CI: 3.5-19.2 mmHg; p = 0.002). CONCLUSIONS Simultaneous paCO2-analysis from right and left distal arterial lines is the method of choice to reduce the risk of adverse effects (e.g. severe respiratory acidosis) while performing AT in VA-ECMO patients during BD determination.
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Affiliation(s)
- Farid Salih
- Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany.
| | - Johann Lambeck
- Dept. of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Albrecht Günther
- Dept. of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Caroline Ferse
- Dept. of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Olaf Hoffmann
- Dept. of Neurology, St. Josefs-Krankenhaus, Allee nach Sanssouci 7, 14471 Potsdam, Germany; Medizinische Hochschule Brandenburg Theodor Fontane, Fehrbelliner Straße 38, 16816 Neuruppin, Germany
| | | | - Andre Finn
- Dept. of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Stephan A Brandt
- Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany
| | - Benjamin Hotter
- Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany
| | - Florian Masuhr
- Dept. of Neurology, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115 Berlin, Germany
| | - Stephan Schreiber
- Dept. of Neurology, Asklepios Fachklinikum, Anton-Saefkow-Allee 2, 14772, Brandenburg, Germany
| | - Florian Weissinger
- Dept. of Neurology, Vivantes Humboldt-Klinikum, Am Nordgraben 2, 13509 Berlin, Germany
| | - Andrea Rocco
- Dept. of Neurology, Klinikum Ernst von Bergmann, Charlottenstraße 72, 14467 Potsdam, Germany
| | - Hauke Schneider
- Dept. of Neurology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Wolf-Dirk Niesen
- Dept. of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, Breisacher Straße 64, 79106 Freiburg, Germany
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Hsieh C, Hsu Y, Chen Y, Liang H, Lin K, Chen W, Wu H, Hunang S, Hung Y. Using extracorporeal membrane oxygenation in donations after cardiac death or brain death: A single-center experience and long-term outcome. Ann Gastroenterol Surg 2024; 8:312-320. [PMID: 38455485 PMCID: PMC10914688 DOI: 10.1002/ags3.12749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/17/2023] [Accepted: 09/29/2023] [Indexed: 03/09/2024] Open
Abstract
Aims The use of extended criteria donors is a routine practice that sometimes involves extracorporeal membrane oxygenation (ECMO) in donations after cardiac death or brain death. Methods We performed a retrospective study in a single center from January 2006 to December 2019. The study included 90 deceased donor liver transplants. The patients were divided into three groups: the donation after brain death (DBD) group (n = 58, 64.4%), the DBD with ECMO group (n = 11, 12.2%) and the donation after cardiac death (DCD) with ECMO group (n = 21, 23.3%). Results There were no significant differences between the DBD with ECMO group and the DBD group. When comparing the DCD with ECMO group and the DBD group, there were statistically significant differences for total warm ischemia time (p < 0.001), total cold ischemia time (p = 0.023), and split liver transplantation (p < 0.001), and there was significantly poor recovery in regard to total bilirubin level (p = 0.027) for the DCD with ECMO group by repeated measures ANOVA. The 5-year survival rates of the DBD, DBD with ECMO, and DCD with ECMO groups were 78.1%, 90.9%, and 75.6%, respectively. The survival rate was not significantly different when comparing the DBD group to either the DBD with ECMO group (p = 0.435) or the DCD with ECMO group (p = 0.310). Conclusions Using ECMO in donations after cardiac death or brain death is a good technology, and it contributed to 35.6% of the liver graft pool.
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Affiliation(s)
- Chia‐En Hsieh
- Department of Nursing, Liver Transplantation CenterChung Shan Medical University HospitalTaichungTaiwan
| | - Ya‐Lan Hsu
- Department of Nursing, Liver Transplantation CenterChung Shan Medical University HospitalTaichungTaiwan
| | - Yao‐Li Chen
- Department of Surgery, Liver Transplantation CenterChung Shan Medical University HospitalTaichungTaiwan
- School of MedicineChung Shan Medical UniversityTaichungTaiwan
| | - Hsin‐Rou Liang
- Department of SurgeryKaohsiung Medical University Chung‐Ho Memorial HospitalKaohsiungTaiwan
| | - Kuo‐Hua Lin
- General SurgeryChanghua Christian HospitalChanghuaTaiwan
| | - Wen‐Yuan Chen
- Department of Pharmacy, Liver Transplantation CenterChung Shan Medical University HospitalTaichungTaiwan
| | - Hsiu‐Man Wu
- Department of NursingChanghua Christian HospitalChanghuaTaiwan
| | - Sin‐Bao Hunang
- Department of Family and Community MedicineChung Shan Medical University HospitalTaichungTaiwan
- Department of Medical Humanities, School of MedicineChung Shan Medical UniversityTaichungTaiwan
| | - Yu‐Ju Hung
- Department of Surgery, Liver Transplantation CenterChung Shan Medical University HospitalTaichungTaiwan
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3
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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Zhao DX, Caturegli G, Wilcox C, Stephens RS, Kim BS, Keller S, Geocadin RG, Suarez JI, Whitman GJR, Cho SM. Challenges in determining death by neurologic criteria in extracorporeal membrane oxygenation - A single center experience. Perfusion 2023:2676591231187548. [PMID: 37387124 PMCID: PMC10756925 DOI: 10.1177/02676591231187548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Apnea test (AT) in patients on extracorporeal membrane oxygenation (ECMO) support is challenging, leading to variation in determining death by neurologic criteria (DNC). We aim to describe the diagnostic criteria and barriers for DNC in adults on ECMO in a tertiary care center. METHODS A retrospective review of a prospective observational standardized neuromonitoring study was conducted in adult VA- and VV-ECMO patients at a tertiary center from June 2016 to March 2022. Brain death was defined according to the 2010 American Academy of Neurology guidelines and following the 2020 World Brain Death Project recommendations for performing AT in ECMO patients. RESULTS Eight (2.7%) ECMO patients (median age = 44 years, 75% male, 50% VA-ECMO) met criteria for DNC, six (75%) of whom were determined with AT. In the other two patients who did not undergo AT due to safety concerns, ancillary tests (transcranial doppler and electroencephalography) were consistent with DNC. An additional seven (2.3%) patients (median age = 55 years, 71% male, 86% VA-ECMO) were noted to have absent brainstem reflexes but failed to complete determination of DNC as they underwent withdrawal of life-sustaining treatment (WLST) before a full evaluation was completed. In these patients, AT was never performed, and ancillary tests were inconsistent with either neurological exam findings and/or neuroimaging supporting DNC, or with each other. CONCLUSION AT was used safely and successfully in 6 of the 8 ECMO patients diagnosed with DNC and was always consistent with the neurological exam and imaging findings, as opposed to ancillary tests alone.
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Affiliation(s)
- David X Zhao
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Wilcox
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - R. Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Romergryko G. Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn JR Whitman
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Dave SB, Deatrick KB, Galvagno SM, Mazzeffi MA, Kaczorowski DJ, Madathil RJ, Rector R, Tabatabai A, Haase DJ, Herr D, Scalea TM, Menaker J. A descriptive evaluation of causes of death in venovenous extracorporeal membrane oxygenation. Perfusion 2023; 38:66-74. [PMID: 34365847 DOI: 10.1177/02676591211035938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become an important support modality for patients with acute respiratory failure refractory to optimal medical therapy, such as low tidal volume mechanical ventilator support, early paralytic infusion, and early prone positioning. The objective of this cohort study was to investigate the causes and timing of in-hospital mortality in patients on VV ECMO. All patients, excluding trauma and bridge to lung transplant, admitted 8/2014-6/2019 to a specialty ICU for VV ECMO were reviewed. Two hundred twenty-five patients were included. In-hospital mortality was 24.4% (n = 55). Most non-survivors (46/55, 84%) died prior to lung recovery and decannulation from VV ECMO. Most common cause of death (COD) for patients who died on VV ECMO was removal of life sustaining therapy (LST) in setting of multisystem organ failure (MSOF) (n = 24). Nine patients died a median of 9 days [6, 11] after decannulation. Most common COD in these patients was palliative withdrawal of LST due to poor prognosis (n = 3). Non-survivors were older and had worse predictive mortality scores than survivors. We found that death in patients supported with VV ECMO in our study most often occurs prior to decannulation and lung recovery. This study demonstrated that the most common cause of death in patients supported with VV ECMO was removal of LST due MSOF. Acute hemorrhage (systemic or intracranial) was not found to be a common cause of death in our patient population.
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Affiliation(s)
- Sagar B Dave
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ronson J Madathil
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond Rector
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Ali Tabatabai
- Division of Pulmonary and Critical Care, Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Department of Emergency Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Herr
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA
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Fatehi Hassanabad A, Kidd WT, Novick RJ, Warshawski F, Kromm JA. Brain death post cardiac surgery: A modified apnea test to confirm death by neurologic criteria for a patient on extracorporeal membrane oxygenation. J Card Surg 2022; 37:1764-1769. [PMID: 35318714 DOI: 10.1111/jocs.16428] [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: 06/23/2021] [Revised: 10/16/2021] [Accepted: 01/02/2022] [Indexed: 11/28/2022]
Abstract
Death by neurologic criteria (DNC) requires coma, absent brainstem reflexes, and the inability to breathe independently during apnea testing (AT). For patients on extracorporeal membrane oxygenation (ECMO), this clinical determination is more challenging. Herein, we report the case of a patient with DNC on ECMO post cardiac surgery, highlighting various considerations to the process and modifications required for AT.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - William T Kidd
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Richard J Novick
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Frank Warshawski
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Julie A Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Critical Care Medicine & Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Chen Z, Su Y, Liu G, Fan L, Zhang Y, Chen W, Ye H, Huang H. Investigation of Apnea Testing During Brain Death Determination in China. ASAIO J 2021; 67:1211-1216. [PMID: 33769346 DOI: 10.1097/mat.0000000000001385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Apnea testing (AT) is one of the key steps for brain death (BD) diagnosis and confirmation. However, the completion rate of AT is not well in China. The aim of this study was to investigate the completion rates of the AT during BD determination in China and analyze the determinant factors. We reviewed and analyzed potential BD patients registered in our database from 2013 to 2019. The patients were divided into those with completed and aborted AT. Preconditions and organ function status were compared between the two groups. A total of 1,531 (1,301 adults and 230 pediatrics) cases of potential BD were extracted, and BD determination was performed 2,185 and 377 times in adults and pediatrics respectively. The nonperformance and aborted rates of AT were 12.2% and 34.5% in adults, and 11.7% and 44.4% in pediatrics respectively. Compared with the completed group, the aborted group had a lower PaO2, systolic blood pressure, PaO2/FiO2 ratios, and higher alveolar-arterial (A-a) gradient both in adults and pediatrics, and higher PaCO2 and higher heart rates in adults. PaO2 and A-a gradient had higher predictive efficacy for AT completion in both adults and pediatrics. The implementation and completion rates of AT are not ideal in China. PaO2 and A-a gradient are important factors for the successful completion of AT and should be optimized before AT.
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Affiliation(s)
- Zhongyun Chen
- From the Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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8
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He T, He J, Wang Z, Cui Z. Modification strategies to improve the membrane hemocompatibility in extracorporeal membrane oxygenator (ECMO). ADVANCED COMPOSITES AND HYBRID MATERIALS 2021; 4:847-864. [PMID: 33969267 PMCID: PMC8091652 DOI: 10.1007/s42114-021-00244-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 05/26/2023]
Abstract
ABSTRACT Since extracorporeal membrane oxygenator (ECMO) has been utilized to save countless lives by providing continuous extracorporeal breathing and circulation to patients with severe cardiopulmonary failure. In particular, it has played an important role during the COVID-19 epidemic. One of the important composites of ECMO is membrane oxygenator, and the core composite of the membrane oxygenator is hollow fiber membrane, which is not only a place for blood oxygenation, but also is a barrier between the blood and gas side. However, the formation of blood clots in the oxygenator is a key problem in the using process. According to the study of the mechanism of thrombosis generation, it was found that improving the hemocompatibility is an efficient approach to reduce thrombus formation by modifying the surface of materials. In this review, the corresponding modification methods (surface property regulation, anticoagulant grafting, and bio-interface design) of hollow fiber membranes in ECMO are classified and discussed, and then, the research status and development prospects are summarized.
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Affiliation(s)
- Ting He
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemistry and Chemical Engineering, Nanjing Tech University, 210009 Nanjing, China
| | - Jinhui He
- National Engineering Research Center for Special Separation Membrane, Nanjing Tech University, 210009 Nanjing, China
| | - Zhaohui Wang
- Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing Tech University, 210009 Nanjing, China
| | - Zhaoliang Cui
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemistry and Chemical Engineering, Nanjing Tech University, 210009 Nanjing, China
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9
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Chiarini G, Cho SM, Whitman G, Rasulo F, Lorusso R. Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach. Semin Neurol 2021; 41:422-436. [PMID: 33851392 DOI: 10.1055/s-0041-1726284] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.
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Affiliation(s)
- Giovanni Chiarini
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frank Rasulo
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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10
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Abstract
Apnea is one of the three cardinal findings in brain death (BD). Apnea testing (AT) is physiologically and practically complex. We sought to review described modifications of AT, safety and complication rates, monitoring techniques, performance of AT on extracorporeal membrane oxygenation (ECMO), and other relevant considerations regarding AT. We conducted a systematic scoping review to answer these questions by searching the literature on AT in English language available in PubMed or EMBASE since 1980. Pediatric or animal studies were excluded. A total of 87 articles matched our inclusion criteria and were qualitatively synthesized in this review. A large body of the literature on AT since its inception addresses a variety of modifications, monitoring techniques, complication rates, ways to perform AT on ECMO, and other considerations such as variability in protocols, lack of uniform awareness, and legal considerations. Only some modifications are widely used, especially methods to maintain oxygenation, and most are not standardized or endorsed by brain death guidelines. Future updates to AT protocols and strive for unification of such protocols are desirable.
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Affiliation(s)
- Katharina M Busl
- Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ariane Lewis
- Neurology and Neurosurgery, NYU Langone Health, New York, NY, USA
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11
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Sahu MK, Vaswani P, Bipin C, Singh SP, Hadda V. Enigma of apnea test for brain death on ECMO—an ongoing discussion—case study and review of literature. Indian J Thorac Cardiovasc Surg 2021; 37:188-191. [PMID: 32904971 PMCID: PMC7462103 DOI: 10.1007/s12055-020-01008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022] Open
Abstract
Coma, absent brain stem reflexes, and apnea are considered the neurological criteria of brain death. As membrane oxygenator does almost entire gas exchange in patients with severely diseased lungs who are on extracorporeal membrane oxygenation (ECMO), it is not possible to carry out apnea test in routine manner. We described the difficulties we faced conducting the apnea test and the other ancillary tests in our patient on veno-venous ECMO who suffered a major cerebral insult and reviewed the literature of brain death testing in patients on ECMO.
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12
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Veiga VC, Silva LMCJ, Sady ERR, Fernandes PV, Rojas SSO. Apnea test for the diagnosis of brain death in a patient undergoing extracorporeal membrane oxygenation. Rev Bras Ter Intensiva 2020; 32:468-473. [PMID: 33053038 PMCID: PMC7595728 DOI: 10.5935/0103-507x.20200077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/10/2020] [Indexed: 11/20/2022] Open
Abstract
Extracorporeal membrane oxygenation is used as extracirculatory support for the care of patients with severe and reversible cardiac and/or respiratory failure. Neurological complications may be related to the procedure. Given the unfavorable neurological evolution and the need to perform a brain death protocol, the performance of an apnea test in this context remains a challenge. We report the use of an apnea test for the diagnosis of brain death post-cardiac surgery in a patient receiving venoarterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Viviane Cordeiro Veiga
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
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13
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Sahu MK, Bipin C, Pahuja S, Singh SP, Hadda V. A 92 Days Run of Venovenous Extracorporeal Membrane Oxygenation. JOURNAL OF CARDIAC CRITICAL CARE TSS 2020. [DOI: 10.1055/s-0040-1716637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Venovenous extracorporeal membrane oxygenation (VV-ECMO) is an established life-saving procedure for severe acute respiratory failure due to various causes. In general, the duration of ECMO ranges from 1 to 2 weeks, with withdrawal recommended if no improvement is noted. We report a case of respiratory failure due to acute respiratory distress syndrome (ARDS) following influenza A infection, supported with a long ECMO run and the lessons learned from this experience.
Case Report A 40-year-old female weighing 120 kg with pneumonia following H1N1 influenza was transferred to our hospital on mechanical ventilation for worsening respiratory distress. On admission, she presented with bilateral diffuse infiltrates on chest X-ray and severe hypoxemia with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen concentration ratio (PaO2/FiO2) of 85 at FiO2 of 0.8 on endotracheal intubation and mechanical ventilation. Acinetobacter Baumannii was isolated from respiratory secretions; antibiotics were revised as per sensitivity. Her respiratory status further deteriorated over next 96 hours in spite of maximally optimized mechanical ventilation. VV-ECMO was established on 4th day of mechanical ventilation in our hospital. Thereafter, she underwent a prolonged ECMO run with respiratory improvement starting to show some promise only by 86th day of ECMO. Weaning process was initiated gradually. However, on 88th day of ECMO the patient had an episode of seizure followed by low Glasgow Coma Scale (GCS) score (3T/15). The patient did not recover from the cerebral insult and based on clinical neurological examination including apnea test, brain death was determined within next 48 hours and the ECMO was called off.
Conclusions Prolonged ECMO therapy poses many challenges and might be considered if the primary cause of respiratory failure necessitating ECMO is expected to resolve or a feasibility of lung transplantation is contemplated. Good team dynamics and appropriate counselling to the family are of utmost importance managing the patients on prolonged ECMO.
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Affiliation(s)
- Manoj Kumar Sahu
- Department of Cardiothoracic and Vascular Surgery, CN Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Chalattil Bipin
- Department of Cardiothoracic and Vascular Surgery, CN Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sourabh Pahuja
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sarvesh Pal Singh
- Department of Cardiothoracic and Vascular Surgery, CN Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India
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Venkatasubba Rao CP, Chatterjee S. Commentary: How to say goodbye. J Thorac Cardiovasc Surg 2020; 162:878-879. [PMID: 32690415 DOI: 10.1016/j.jtcvs.2020.04.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Chethan P Venkatasubba Rao
- Section of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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Sady ERR, Junqueira L, Veiga VC, Rojas SSO. Apnea test for brain death diagnosis in adults on extracorporeal membrane oxygenation: a review. Rev Bras Ter Intensiva 2020; 32:312-318. [PMID: 32667442 PMCID: PMC7405745 DOI: 10.5935/0103-507x.20200048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/28/2020] [Indexed: 12/05/2022] Open
Abstract
Among the potential complications of extracorporeal membrane oxygenation, neurological dysfunctions, including brain death, are not negligible. In Brazil, the diagnostic process of brain death is regulated by Federal Council of Medicine resolution 2,173 of 2017. Diagnostic tests for brain death include the apnea test, which assesses the presence of a ventilatory response to hypercapnic stimulus. However, gas exchange, including carbon dioxide removal, is maintained under extracorporeal membrane oxygenation, making the test challenging. In addition to the fact that the aforementioned resolution does not consider the specificities of the diagnostic process under extracorporeal membrane oxygenation, studies on the subject are scarce. This review aims to identify case studies (and/or case series) published in the PubMed® and Cochrane databases describing the process of brain death diagnosis. A total of 17 publications (2011 - 2019) were identified. The practical strategies described were to provide pretest supplemental oxygenation via mechanical ventilation and extracorporeal membrane oxygenation (fraction of inspired oxygen = 1.0) and, at the beginning of the test, titrate the sweep flow (0.5 - 1.0L/minute) to minimize carbon dioxide removal. It is also recommended to increase blood flow and/or sweep flow in the presence of hypoxemia and/or hypotension, which may be combined with fluid infusion and/or the escalation of inotropic/vasoactive drugs. If the partial pressure of carbon dioxide threshold is not reached, repeating the test under supplementation of carbon dioxide exogenous to the circuit is an alternative. Last, in cases of venoarterial extracorporeal membrane oxygenation, to measure gas variation and exclude differential hypoxia, blood samples of the native and extracorporeal (post-oxygenator) circulations are recommended.
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Affiliation(s)
| | - Lígia Junqueira
- Unidade de Terapia Intensiva Neurológica, Hospital Beneficência Portuguesa, São Paulo, SP, Brasil
| | - Viviane Cordeiro Veiga
- Unidade de Terapia Intensiva Neurológica, Hospital Beneficência Portuguesa, São Paulo, SP, Brasil
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17
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Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study. Intensive Care Med 2020; 46:973-982. [DOI: 10.1007/s00134-020-05926-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/08/2020] [Indexed: 11/26/2022]
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