1
|
Meyer AD, Thorpe CR, Fraker T, Cancio T, Rocha J, Willis RP, Cap AP, Gailani D, Shatzel JJ, Tucker EI, McCarty OJ. Factor XI Inhibition With Heparin Reduces Clot Formation in Simulated Pediatric Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:1074-1082. [PMID: 37801726 PMCID: PMC10841048 DOI: 10.1097/mat.0000000000002048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) supplies circulatory support and gas exchange to critically ill patients. Despite the use of systemic anticoagulation, blood exposure to ECMO surfaces causes thromboembolism complications. Inhibition of biomaterial surface-mediated activation of coagulation factor XI (FXI) may prevent device-associated thrombosis. Blood was collected from healthy volunteers (n = 13) following the U.S. Army Institute of Surgical Research standard operating procedure for testing in an ex vivo ECMO circuit. A roller-pump circuit circulated either 0.5 U/ml of unfractionated heparin alone or in combination with the anti-FXI immunoglobulin G (IgG) (AB023) for 6 hours or until clot formation caused device failure. Coagulation factor activity, platelet counts, time to thrombin generation, peak thrombin, and endogenous thrombin potential were quantified. AB023 in addition to heparin sustained circuit patency in all tested circuits (5/5) after 6 hours, while 60% of circuits treated with heparin alone occluded (3/8), log-rank p < 0.03. AB023 significantly prolonged the time to clot formation as compared to heparin alone (15.5 vs . 3.3 minutes; p < 0.01) at the 3-hour time point. AB023 plus heparin significantly reduced peak thrombin compared to heparin alone (123 vs . 217 nM; p < 0.01). Inhibition of contact pathway activation of FXI may be an effective adjunct to anticoagulation in extracorporeal life support.
Collapse
Affiliation(s)
- Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX
- Organ Support & Automation Technologies, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, TX
| | | | - Tamara Fraker
- The Geneva Foundation, San Antonio Military Medical Center, Ft. Sam Houston, TX
| | | | | | | | - Andrew P. Cap
- Organ Support & Automation Technologies, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, TX
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Joseph J. Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, OR
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
- Aronora, Inc., Portland, OR
| |
Collapse
|
2
|
Maul TM, Herrera G. Coagulation and hemolysis complications in neonatal ECLS: Role of devices. Semin Fetal Neonatal Med 2022; 27:101405. [PMID: 36437186 DOI: 10.1016/j.siny.2022.101405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neonatal extracorporeal life support (ECLS) has enjoyed a long history of successful patient support for both cardiac and respiratory failure. The small size of this patient population has provided many technical challenges from cannulation to pumps and oxygenators. This is further complicated by the relatively meager commercial options for equipment owing to the relatively low utilization of neonatal ECLS compared to adults, which has exploded following the H1N1 epidemic and the availability of the polymethylpentene oxygenator. This paper focuses on the impact of equipment choices on thrombosis and hemolysis in neonatal ECLS and the underlying mechanisms behind them. Based upon the available evidence, it is clear neonatal ECLS requires careful attention to the selection and operation of all parts of the ECLS system. Practitioners should also be aware of the factors that increase blood cell fragility, which can impact decisions around equipment and subsequent operation.
Collapse
Affiliation(s)
- Timothy M Maul
- Nemours Children's Health Florida, Cardiac Center, Orlando, FL, USA; University of Pittsburgh, Department of Bioengineering, Pittsburgh, PA, USA; University of Central Florida College of Medicine, Orlando, FL, USA.
| | - Guillermo Herrera
- Children's National Hospital, 111 Michigan Ave, NW, Washington, D.C., USA.
| |
Collapse
|
3
|
Chu JH, Sarathy S, Ramesh S, Rudolph K, Raghavan ML, Badheka A. Risk factors for hemolysis with centrifugal pumps in pediatric extracorporeal membrane oxygenation: Is pump replacement an answer? Perfusion 2022; 38:771-780. [PMID: 35354417 DOI: 10.1177/02676591221082499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Hemolysis during pediatric extracorporeal membrane oxygenation (ECMO) is associated with increased risk for renal failure and mortality. OBJECTIVES We aim to describe risk factors for hemolysis in pediatric ECMO supported by centrifugal pumps. METHODS We conducted an analysis of retrospective data collected at an academic children's hospital from January 2017 to December 2019. MEASUREMENTS AND RESULTS Plasma-free hemoglobin (PFH) levels were measured daily, and hemolysis was defined as PFH>50 mg/dL. Of 46 ECMO runs over 528 ECMO days, hemolysis occurred in 23 (58%) patients over a total of 40 (8%) ECMO days. In multivariable logistic regression models, VA-ECMO (aOR=4.69, 95% CI: 1.01-21.83) and higher hemoglobin (aOR = 1.38, 95% CI: 1.06-1.81) were independently associated with hemolysis. There were also non-significant trends toward increased risk for hemolysis with higher rotational pump speed (aOR=2.39, 95% CI: 0.75-7.65), higher packed red blood cell transfusions (aOR=1.15, 95% CI: 0.99-1.34), and higher cryoprecipitate transfusions (aOR=2.01, 95% CI: 0.83-4.86). Isolated pump exchanges that were performed in 12 patients with hemolysis led to significant decreases in PFH levels within 24 h (89 vs 11 mg/dL, p<0.01). CONCLUSIONS Hemolysis is common in pediatric ECMO using centrifugal pumps. Avoidance of high pump speeds and conservative administration of blood products may help to mitigate the risk for hemolysis. Furthermore, pump exchange may be an effective first-line treatment for hemolysis.
Collapse
Affiliation(s)
- Jian H Chu
- 2468University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Internal Medicine, 20512Rush University Medical Center, Chicago, IL, USA
| | - Srivats Sarathy
- 4083University of Iowa Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA
| | - Sonali Ramesh
- Division of Pediatric Critical Care, Department of Pediatrics, 21827University of Iowa Stead Family Children's Hospital, Iowa City, IA 52242, USA
| | - Kristina Rudolph
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Madhavan L Raghavan
- 4083University of Iowa Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA
| | - Aditya Badheka
- Division of Pediatric Critical Care, Department of Pediatrics, 21827University of Iowa Stead Family Children's Hospital, Iowa City, IA 52242, USA
| |
Collapse
|
4
|
Hendrix RHJ, Kurniawati ER, Schins SFC, Maessen JG, Weerwind PW. Dynamic oxygenator blood volume during prolonged extracorporeal life support. PLoS One 2022; 17:e0263360. [PMID: 35108345 PMCID: PMC8809600 DOI: 10.1371/journal.pone.0263360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/17/2022] [Indexed: 11/19/2022] Open
Abstract
Current methods for identification of oxygenator clotting during prolonged extracorporeal life support include visual inspection, evaluation of oxygenator resistance and oxygen exchange performance, and assessment of clotting-related laboratory parameters. However, these observations do not provide a quantitative assessment of oxygenator clot formation. By measuring changes in the dynamic oxygenator blood volume this study aimed to evaluate the relation to oxygenator resistance and oxygen transfer performance. Sixty-seven oxygenators were studied during adult extracorporeal life support. Oxygenator blood volume, oxygenator resistance, and oxygen transfer efficiency were monitored. Oxygenator blood volume decreased with increasing runtime (r = -0.462; p <0.001). There was a statistically significant, fair negative correlation between oxygenator blood volume and oxygenator resistance (r = -0.476; p<0.001) in all oxygenators, which became stronger analyzing only exchanged oxygenators (r = -0.680; p<0.001) and oxygenators with an oxygenator blood volume <187 mL (r = 0.831; p<0.001). No relevant correlation between oxygenator blood volume and O2 transfer was found. Oxygenator blood volume declined over time and was clearly associated with an increasing oxygenator resistance during prolonged extracorporeal life support, though O2 transfer was less affected.
Collapse
Affiliation(s)
- Rik H. J. Hendrix
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- * E-mail:
| | - Eva R. Kurniawati
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sanne F. C. Schins
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jos G. Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patrick W. Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
5
|
Liu Q, Del Prete L, Hassan A, Pezzati D, Bilancini M, D'Amico G, Diago Uso T, Hashimoto K, Aucejo F, Fujiki M, Sasaki K, Kwon CHD, Eghtesad B, Miller C, Quintini C. Two pumps or one pump? A comparison of human liver normothermic machine perfusion devices for transplantation. Artif Organs 2021; 46:859-866. [PMID: 34904245 DOI: 10.1111/aor.14150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Normothermic machine perfusion provides continuous perfusion to ex situ hepatic grafts through the portal vein and the hepatic artery. Because the portal vein has high flow with low pressure and the hepatic artery has low flow with high pressure, different types of perfusion machines have been employed to match the two vessels' infusion hemodynamics. METHODS We compared transplanted human livers perfused through a 2-pump (n = 9) versus a 1-pump perfusion system (n = 6) where a C-clamp is used as a tubing constrictor to regulate hemodynamics. RESULTS There was no significant difference between groups in portal vein or hepatic artery flow rate. The 1-pump group had more hemoglobin in the perfusate. However, there was no significant difference in plasma hemoglobin between the 2-pump and 1-pump groups at each time point or in the change in levels, proving no hemolysis occurred due to C-clamp tube constriction. After transplantation, the 2-pump group had two cases of early allograft dysfunction (EAD), whereas the 1-pump group had no EAD. There was no graft failure or patient death in either group during follow-up ranging from 20-52 months. CONCLUSIONS Our data show that the 1-pump design provided the same hemodynamic output as the 2-pump design, with no additional hemolytic risk, but with the benefits of lower costs, easier transport and faster and simpler setting.
Collapse
Affiliation(s)
- Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luca Del Prete
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ahmed Hassan
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniele Pezzati
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mary Bilancini
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Federico Aucejo
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kazunari Sasaki
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Bijan Eghtesad
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | |
Collapse
|
6
|
Hugenroth K, Borchardt R, Ritter P, Groß-Hardt S, Meyns B, Verbelen T, Steinseifer U, Kaufmann TAS, Engelmann UM. Optimizing cerebral perfusion and hemodynamics during cardiopulmonary bypass through cannula design combining in silico, in vitro and in vivo input. Sci Rep 2021; 11:16800. [PMID: 34408243 PMCID: PMC8373878 DOI: 10.1038/s41598-021-96397-2] [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: 05/20/2021] [Accepted: 08/03/2021] [Indexed: 11/09/2022] Open
Abstract
Cardiopulmonary bypass (CPB) is a standard technique for cardiac surgery, but comes with the risk of severe neurological complications (e.g. stroke) caused by embolisms and/or reduced cerebral perfusion. We report on an aortic cannula prototype design (optiCAN) with helical outflow and jet-splitting dispersion tip that could reduce the risk of embolic events and restores cerebral perfusion to 97.5% of physiological flow during CPB in vivo, whereas a commercial curved-tip cannula yields 74.6%. In further in vitro comparison, pressure loss and hemolysis parameters of optiCAN remain unaffected. Results are reproducibly confirmed in silico for an exemplary human aortic anatomy via computational fluid dynamics (CFD) simulations. Based on CFD simulations, we firstly show that optiCAN design improves aortic root washout, which reduces the risk of thromboembolism. Secondly, we identify regions of the aortic intima with increased risk of plaque release by correlating areas of enhanced plaque growth and high wall shear stresses (WSS). From this we propose another easy-to-manufacture cannula design (opti2CAN) that decreases areas burdened by high WSS, while preserving physiological cerebral flow and favorable hemodynamics. With this novel cannula design, we propose a cannulation option to reduce neurological complications and the prevalence of stroke in high-risk patients after CPB.
Collapse
Affiliation(s)
- Kristin Hugenroth
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany. .,Enmodes GmbH, Aachen, Germany.
| | | | | | - Sascha Groß-Hardt
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.,Enmodes GmbH, Aachen, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tim A S Kaufmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.,Enmodes GmbH, Aachen, Germany
| | - Ulrich M Engelmann
- Enmodes GmbH, Aachen, Germany. .,Department of Medical Engineering and Applied Mathematics, FH Aachen University of Applied Sciences, Jülich, Germany.
| |
Collapse
|
7
|
Erdem Ö, Kuiper JW, Houmes RJ, van Ommen CH, van Rosmalen J, Tibboel D, Wildschut ED. Coagulation complications after conversion from roller to centrifugal pump in neonatal and pediatric extracorporeal membrane oxygenation. J Pediatr Surg 2021; 56:1378-1385. [PMID: 33279215 DOI: 10.1016/j.jpedsurg.2020.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/01/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Coagulation complications are frequent, unwanted occurrences in extracorporeal membrane oxygenation (ECMO) treatment, possibly influenced by the pump in the ECMO-circuit. We hypothesized that fewer complications would occur with a smaller, heparin-coated ECMO system with a centrifugal pump (CP) than with one with a roller pump (RP) and that after conversion, complication rates would decrease over time. METHODS This single-center, retrospective chart study included all first neonatal and pediatric ECMO runs between 2009 and 2015. Differences between groups were assessed with Mann-Whitney U tests and Kruskal-Wallis tests. Determinants of complication rates were evaluated through Poisson regression models. The CP group was divided into three consecutive groups to assess whether complication rates decreased over time. RESULTS The RP group comprised 90 ECMO runs and the CP group 82. Hemorrhagic complication rates were significantly higher with the CP than with the RP, without serious therapeutic consequences, while thrombotic complications rates were unaffected. Intracranial hemorrhage rates and coagulation-related mortality rates were similar. Gained experience with the CP did not improve complication rates or survival over time. CONCLUSIONS Although the CP seems safe, it does not seem beneficial over the RP. Further research is warranted on how pump type affects coagulation, taking into account the severity and implications of coagulation complications. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Özge Erdem
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Jan Willem Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.
| | - Robert Jan Houmes
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Cornelia Heleen van Ommen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Enno Diederik Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| |
Collapse
|
8
|
Syed A, Kerdi S, Qamar A. Bioengineering Progress in Lung Assist Devices. Bioengineering (Basel) 2021; 8:89. [PMID: 34203316 PMCID: PMC8301204 DOI: 10.3390/bioengineering8070089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/31/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
Artificial lung technology is advancing at a startling rate raising hopes that it would better serve the needs of those requiring respiratory support. Whether to assist the healing of an injured lung, support patients to lung transplantation, or to entirely replace native lung function, safe and effective artificial lungs are sought. After 200 years of bioengineering progress, artificial lungs are closer than ever before to meet this demand which has risen exponentially due to the COVID-19 crisis. In this review, the critical advances in the historical development of artificial lungs are detailed. The current state of affairs regarding extracorporeal membrane oxygenation, intravascular lung assists, pump-less extracorporeal lung assists, total artificial lungs, and microfluidic oxygenators are outlined.
Collapse
Affiliation(s)
- Ahad Syed
- Nanofabrication Core Lab, King Abdullah University of Science and Technology, Thuwal 23955-6900, Saudi Arabia;
| | - Sarah Kerdi
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Saudi Arabia;
| | - Adnan Qamar
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Saudi Arabia;
| |
Collapse
|
9
|
Sargent CR, Perkins IL, Kanamarlapudi V, Moriarty C, Ali S. Hemodilution Increases the Susceptibility of Red Blood Cells to Mechanical Shear Stress During In Vitro Hemolysis Testing. ASAIO J 2021; 67:632-641. [PMID: 32947284 DOI: 10.1097/mat.0000000000001280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The American Society for Testing and Materials (ASTM) F1841 standard for the assessment of hemolysis in blood pumps recommends using phosphate-buffered saline (PBS) for hemodilution to standardize hematocrit (HCT). However, PBS increases red blood cell mechanical fragility and hemolysis. Herein, we investigated diluents and dilutions during in vitro testing to reduce hemodilution bias when assessing hemolysis. Bovine blood was diluted with either PBS or PBS + 4/6 g% bovine serum albumin (BSA) to a 70/90% blood dilution, or to an HCT of 30% ± 2%, and pumped with the CentriMag or RotaFlow under hemodynamic conditions. Separately, bovine and human blood were subjected to ventricular assist device-like shear stress using a vortex. Plasma-free hemoglobin levels, normalized milligram index of hemolysis (mgNIH), and protein concentrations were analyzed. Hemolysis depended on the diluent and final blood concentration. Seventy percent of blood diluted with PBS alone caused significantly greater hemolysis than PBS + 4/6 g% BSA. However, at 90% blood, PBS + 4/6 g% BSA caused significantly greater hemolysis than PBS alone. Hence, a positive correlation between mgNIH and hemodilution was observed with PBS and a negative correlation with PBS + 4g% BSA. PBS alone significantly reduced the total protein concentration. Hemodilution with BSA maintains protein concentration within a physiologic range and reduces bias during hemolysis testing at high blood dilutions. Thus, American Society for Testing and Materials standards could consider including BSA as a diluent, when and as required: where large dilution is required (<83%) use PBS + 4 g% BSA, otherwise use PBS alone.
Collapse
Affiliation(s)
- Christian R Sargent
- From the Calon Cardio-Technology Ltd, ILS2, Singleton Park, Swansea, United Kingdom
- Swansea University Medical School, ILS1, Singleton Park, Swansea, United Kingdom
| | - Ina Laura Perkins
- Swansea University Medical School, ILS1, Singleton Park, Swansea, United Kingdom
- R&D, Scandinavian Real Heart AB, Vaesteras, Sweden
| | | | - Christopher Moriarty
- From the Calon Cardio-Technology Ltd, ILS2, Singleton Park, Swansea, United Kingdom
| | - Sabrina Ali
- From the Calon Cardio-Technology Ltd, ILS2, Singleton Park, Swansea, United Kingdom
| |
Collapse
|
10
|
Impact of Circuit Size on Coagulation and Hemolysis Complications in Pediatric Extracorporeal Membrane Oxygenation. ASAIO J 2021; 66:1048-1053. [PMID: 31977350 DOI: 10.1097/mat.0000000000001121] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) circuit volume, patient size, and blood flow may influence coagulation and hemolysis complications. We performed a single-center retrospective analysis of ECMO patients over a 6.5 year period. In 299 ECMO runs, 13% required coagulation-associated circuit changes. Respiratory ECMO was associated with coagulation-associated circuit changes [odds ratio (O/R) 2.8, p < 0.05] and developed severe (plasma-free hemoglobin [pfHb] > 100 mg/dl) hemolysis (O/R 2.3, p < 0.05). Severe hemolysis and component changes were associated with hospital mortality (O/R 2.3 and 2.5, respectively, p < 0.05). The activated partial thromboplastin time (aPTT) to residence time (RT) ratio (aPTT/RT) was used as a surrogate for coagulation risk. We found that aPTT/RT > 2.5 more than doubled time to circuit change (3-8 days, p < 0.05), but aPTT/RT > 3 increased bleeding risks and hospital mortality (O/R 1.8; p < 0.1). Hemolysis was associated with patient weight and circuit to patient volume ratio (CPVR) (p < 0.05), but not pump type. Hemolysis slightly increased with transfusion (p = 0.08), and transfusion requirements increased for CPVR >50% (p < 0.1).Our data suggest that pediatric respiratory ECMO patients are more likely to develop coagulation and hemolysis complications, which are associated with increased mortality. This may result from higher inflammatory processes, which affect coagulation and red cell fragility. Minimizing circuit volume, inflammation, and red cell stress may help to reduce these two complications and their associated mortality.
Collapse
|
11
|
Kaluza M, May B, Doenst T. Using a roller pump for establishing extra-corporal membrane oxygenation (ECMO) - technical considerations for times of crisis. Perfusion 2021; 37:229-234. [PMID: 33637027 PMCID: PMC9019428 DOI: 10.1177/0267659121996182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objective: The COVID-19 pandemic requires thinking about alternatives to establish ECMO when often-limited hardware resources are exhausted. Heart-lung-machines may potentially be used for ECMO but contain roller pumps as compared to centrifugal pumps in ECMO-circuits. We here tested roller pumps as rescue pump for ECMO-establishment. Methods: We set up in vitro circuits on roller pumps from C5 heart-lung-machine with 5 l/minutes flow. In two series, we placed either PVC or silicon tubing for an ECMO circuit into the roller pump. We assessed the mechanical stress on the tubing (aiming to run the pump for at least 1 week), measured the temperature increase generated by the friction and assessed flow characteristics and its measurement in simulated situations resembling tube kinking and suction. Results: The roller pumps led to expected and unexpected adverse events. PVC tubing burst between 36 and 78 hours, while silicon tubing lasted for at least 7 days. At 7 days, the silicone tubing showed significant signs of roller pump wear visible on the outside. The inside, however, was free of surface irregularities. Using these tubings in a roller pump led to a remarkable increase in circuit temperature (PVC: +12.0°C, silicone +2.9°C). Kinking or suction on the device caused the expected dramatic flow reduction (as assessed by direct measurement) while the roller pump display continued to show the preset flow. The roller pump is therefore not able to reliably determine the true flow rate. Conclusion: Roller pumps with silicone tubing but not PVC tubing may be used for running ECMO circuits. Silicone tubing may endure the roller pump shear forces for up to 1 week. Thus, repeated tubing repositioning may be a solution. Circuit heating and substantial limitations in flow detection should increase attention if clinical use in situations of crisis is considered.
Collapse
Affiliation(s)
- Mirko Kaluza
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Benjamin May
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| |
Collapse
|
12
|
Johnson KN, Carr B, Mychaliska GB, Hirschl RB, Gadepalli SK. Switching to centrifugal pumps may decrease hemolysis rates among pediatric ECMO patients. Perfusion 2021; 37:123-127. [DOI: 10.1177/0267659120982572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent advances in ECLS technology have led to the adoption of centrifugal pumps for the majority of patients worldwide. Despite several advantages of centrifugal pumps, they remain controversial because a number of studies have shown increased rates of hemolysis. The aim of this study was to assess the impact of transitioning from roller to centrifugal pumps on hemolysis rates at our center. A retrospective analysis of all pediatric ECMO patients at a single center between 2005 and 2017 was undertaken. Hemolysis was defined as a plasma free hemoglobin >50 mg/dL. Multivariable logistic regression was performed correcting for several factors to determine risk factors for hemolysis and analyze outcomes among patients with hemolysis. Significant findings were those with p < 0.05. A total of 590 patients were identified during the study period. Multivariable logistic regression for risk factors for hemolysis showed roller pumps (OR 1.92, CI 1.11–3.33) and ECMO duration (OR 1.002 per hour, CI 1.00–1.01) to be significant factors. Rates of hemolysis significantly improved following conversion from roller to centrifugal pumps, with significantly lower rates of hemolysis in 2012, 2015, 2016, and 2017 when compared to the historical average with roller pumps from 2005 to 2009 (34.7%). Additionally, hemolysis was associated with an increased risk of death (OR 3.59, CI 2.05–6.29) when correcting for other factors. These data suggest decreasing rates of hemolysis with centrifugal pumps compared to roller pumps. Since hemolysis was also associated with increased risk of death, these data support the switch from roller to centrifugal pumps at ECMO centers.
Collapse
Affiliation(s)
- Kevin N Johnson
- Division of Pediatric Surgery, Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Benjamin Carr
- General Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Ronald B Hirschl
- Division of Pediatric Surgery, Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Mott Children’s Hospital, Ann Arbor, MI, USA
| |
Collapse
|
13
|
Martucci G, di Francesco F, Panarello G, Piazza M, de Ville de Goyet J, Arcadipane A. Inferior vena cava surgical cannulation for infants needing veno-venous extracorporeal membrane oxygenation. Perfusion 2021; 37:128-133. [PMID: 33412989 DOI: 10.1177/0267659120987089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Femoral cannulation for veno-venous extracorporeal membrane oxygenation is challenging in infants because of the diameter of the vein. CASE REPORT Prolonged ECMO support (67 days) was necessary for an 8-month-old (8 kg) girl with acute respiratory distress syndrome that was caused by H1N1 influenza. After 30 days on ECMO support and using a single 16 Fr double-lumen cannula (internal jugular vein), a second cannula was necessary to ensure adequate flow. This second 12 Fr single-lumen cannula was surgically placed through the right common iliac vein. An excellent flow profile was then achieved and ECMO continued successfully for 37 more days. DISCUSSION As a lifesaving option, this double caval configuration successfully optimized the flow profile and oxygenation, outweighing the related risks. CONCLUSION In small children, a surgical approach to the inferior vena cava can be considered safe, especially in those cases where there is a shortage of adequate cannulas, or when central venous access is difficult.
Collapse
Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Fabrizio di Francesco
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Marcello Piazza
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Jean de Ville de Goyet
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| |
Collapse
|
14
|
Garg M. Intravascular Hemolysis and Complications During Extracorporeal Membrane Oxygenation. Neoreviews 2020; 21:e728-e740. [PMID: 33139510 DOI: 10.1542/neo.21-11-e728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) remains a crucial lifesaving therapy for critically ill neonates with severe cardiorespiratory failure. Both the roller pump as well as the centrifugal pump are safe and efficient systems, and some red blood cell breakdown and hemolysis occurs in all ECMO systems. The roller pump functions by gravity whereas the centrifugal pump promotes the flow of blood by a magnetically driven spinning rotor to generate negative pressure. Extracorporeal Life Support Organization data indicate a significant increase in intravascular hemolysis in neonatal and pediatric patients receiving ECMO when the centrifugal pump is used compared with its use in adults. Risk factors for developing hemolysis during ECMO are small cannula size, high negative inlet pressure in the pump head, and thrombosis in the pump head and oxygenator. Excessive red blood cell breakdown and release of plasma free hemoglobin (pfHb) saturate physiologic neutralizing mechanisms such as haptoglobin and hemopexin. The increase in pro-oxidant and proinflammatory pfHb levels causes endothelial dysfunction in a dose-dependent manner. Hemolysis also increases the risk of in-hospital morbidities such as renal injury, direct hyperbilirubinemia, and thrombosis without an increase in mortality in patients receiving ECMO. Hemolysis is an unavoidable side effect of current ECMO technology and there are no approved treatments or treatment guidelines for the neonatal population. Therefore, increased vigilance, recognition of the severity of the hemolytic process, and prompt management are essential to prevent severe endothelial injury leading to proinflammatory and prothrombotic events.
Collapse
Affiliation(s)
- Meena Garg
- Department of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA
| |
Collapse
|
15
|
Koh LY, Hwang NC. Red-Colored Urine in the Cardiac Surgical Patient-Diagnosis, Causes, and Management. J Cardiothorac Vasc Anesth 2020; 35:3774-3788. [PMID: 33199113 DOI: 10.1053/j.jvca.2020.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022]
Abstract
Red-colored urine occurring in the intraoperative and early postoperative periods after cardiac surgery is often a cause for concern. This observation may be a result of hematuria from pathology within the urinary tract, anticoagulant-related nephropathy, drug-induced acute interstitial nephropathy, excretion of heme pigment-containing proteins, such as myoglobin and hemoglobin, and hemolysis occurring during extracorporeal circulation. Within the kidneys, heme-containing compounds result in pigment nephropathy, which is a significant contributory factor to cardiac surgery-associated acute kidney injury. Concerted efforts to reduce red blood cell damage during cardiopulmonary bypass, together with early recognition of the at-risk patient and the institution of prompt therapeutic intervention, may improve outcomes. This review addresses the diagnosis, causes, and management of red-discolored urine occurring during and after cardiac surgery.
Collapse
Affiliation(s)
- Li Ying Koh
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
| |
Collapse
|
16
|
Guihaire J, Haddad F, Hoppenfeld M, Amsallem M, Christle JW, Owyang C, Shaikh K, Hsu JL. Physiology of the Assisted Circulation in Cardiogenic Shock: A State-of-the-Art Perspective. Can J Cardiol 2020; 36:170-183. [PMID: 32036862 PMCID: PMC7121859 DOI: 10.1016/j.cjca.2019.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 01/18/2023] Open
Abstract
Mechanical circulatory support (MCS) has made rapid progress over the last 3 decades. This was driven by the need to develop acute and chronic circulatory support as well as by the limited organ availability for heart transplantation. The growth of MCS was also driven by the use of extracorporeal membrane oxygenation (ECMO) after the worldwide H1N1 influenza outbreak of 2009. The majority of mechanical pumps (ECMO and left ventricular assist devices) are currently based on continuous flow pump design. It is interesting to note that in the current era, we have reverted from the mammalian pulsatile heart back to the continuous flow pumps seen in our simple multicellular ancestors. This review will highlight key physiological concepts of the assisted circulation from its effects on cardiac dynamic to principles of cardiopulmonary fitness. We will also examine the physiological principles of the ECMO-assisted circulation, anticoagulation, and the haemocompatibility challenges that arise when the blood is exposed to a foreign mechanical circuit. Finally, we conclude with a perspective on smart design for future development of devices used for MCS.
Collapse
Affiliation(s)
- Julien Guihaire
- Department of Cardiac Surgery, Research and Innovation Unit, RHU BioArt Lung 2020, Marie Lannelongue Hospital, Paris-Sud University, Le Plessis-Robinson, France.
| | - Francois Haddad
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Mita Hoppenfeld
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Myriam Amsallem
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Clark Owyang
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Khizer Shaikh
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joe L Hsu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
17
|
Meyer AD, Rishmawi AR, Kamucheka R, Lafleur C, Batchinsky AI, Mackman N, Cap AP. Effect of blood flow on platelets, leukocytes, and extracellular vesicles in thrombosis of simulated neonatal extracorporeal circulation. J Thromb Haemost 2020; 18:399-410. [PMID: 31628728 PMCID: PMC7350929 DOI: 10.1111/jth.14661] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has frequent and sometimes lethal thrombotic complications. The role that activated platelets, leukocytes, and small (0.3-micron to 1-micron) extracellular vesicles (EVs) play in ECMO thrombosis is not well understood. OBJECTIVES To test the effect of blood flow rate on the generation of activated platelets, leukocytes, and EVs in a simulated neonatal ECMO circuit using heparinized human whole blood. METHODS Simulated neonatal roller pump circuits circulated whole blood at low, nominal, and high flow rates (0.3, 0.5, and 0.7 L/min) for 6 h. Coagulopathy was defined by thromboelastography (TEG), STA® -procoagulant phospholipid clot time (STA®- Procoag-PPL), and calibrated automated thrombogram. High-resolution flow cytometry measured the cellular expression of prothrombotic phospholipids and proteins on platelets, leukocytes, and EV. RESULTS Despite heparinization, occlusive thrombosis halted flow in two of five circuits at 0.3 L/min and three of five circuits at 0.7 L/min. None of the five circuits at 0.5 L/min exhibited occlusive thrombosis. Phosphatidylserine (PS)-positive platelets and EVs increased at all flow rates more than blood under static conditions (P < .0002). Tissue factor (TF)-positive leukocytes and EVs increased only in low-flow and high-flow circuits (P < .0001). Tissue factor pathway inhibitor (TFPI), at 50 times more than the concentration in healthy adults, failed to suppress thrombin initiation in low-flow and high-flow circuits. CONCLUSIONS This in vitro study informs ECMO specialists to avoid low and high blood flow that increases TF expression on leukocytes and EVs, which likely initiate clot formation. Interventions to decrease TF generated by ECMO may be an effective approach to decrease thrombosis.
Collapse
Affiliation(s)
- Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio, Texas
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Anjana R. Rishmawi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio, Texas
| | - Robin Kamucheka
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Crystal Lafleur
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Andriy I. Batchinsky
- Extracorporeal Life Support, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Nigel Mackman
- Thrombosis and Hemostasis Program, Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew P. Cap
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| |
Collapse
|
18
|
Valencia E, Nasr VG. Updates in Pediatric Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2019; 34:1309-1323. [PMID: 31607521 DOI: 10.1053/j.jvca.2019.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/28/2023]
Abstract
Extracorporeal membrane oxygenation is an increasingly used mode of life support for patients with cardiac and/or respiratory failure refractory to conventional therapy. This review provides a synopsis of the evolution of extracorporeal life support in neonates, infants, and children and offers a framework for areas in need of research. Specific aspects addressed are the changing epidemiology; technologic advancements in extracorporeal membrane oxygenation circuitry; the current status and future direction of anticoagulation management; sedative and analgesic strategies; and outcomes, with special attention to the lessons learned from neonatal survivors.
Collapse
Affiliation(s)
- Eleonore Valencia
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
19
|
Trivedi P, Glass K, Clark JB, Myers JL, Cilley RE, Ceneviva G, Wang S, Kunselman AR, Ündar A. Clinical outcomes of neonatal and pediatric extracorporeal life support: A seventeen‐year, single institution experience. Artif Organs 2019; 43:1085-1091. [DOI: 10.1111/aor.13512] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/21/2019] [Accepted: 05/31/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Payal Trivedi
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Kristen Glass
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Joseph B. Clark
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
- Department of Surgery Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - John L. Myers
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
- Department of Surgery Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Robert E. Cilley
- Department of Surgery Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Gary Ceneviva
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Shigang Wang
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Allen R. Kunselman
- Department of Public Health Sciences Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| | - Akif Ündar
- Department of Pediatrics Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
- Department of Surgery Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
- Department of Bioengineering Penn State Health Children’s Hospital, Penn State College of Medicine Hershey Pennsylvania
| |
Collapse
|
20
|
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with respiratory and cardiac failure refractory to maximal medical management. The extracorporeal life support organization registry is the largest available resource for describing the population and outcomes of patients treated with this therapy. The use of ECMO for neonatal patients is decreasing in proportion to the total annual ECMO runs most likely due to advancements in medical management. Although the overall survival for neonatal ECMO has decreased, this is likely a reflection of the increasingly complex neonatal patients treated with this therapy. Although many patient and mechanical complications are decreasing over time, there remains a high percentage of morbidities and risks associated with ECMO. Continued refinements in management strategies are important to improving overall patient outcomes.
Collapse
Affiliation(s)
- Burhan Mahmood
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, One Children's Hospital Dr, 2133 Faculty Pavilion, 4401 Penn Ave, Pittsburgh, PA 15224.
| | - Debra Newton
- Extracorporeal Support Department, Children's Mercy Kansas City, Kansas City, MO
| | - Eugenia K Pallotto
- Extracorporeal Support Department, Children's Mercy Kansas City, Kansas City, MO; Department of Pediatrics, University of Missouri School of Medicine, Intensive Care Nursery and Neonatal ECMO Children's Mercy, Kansas City, MO
| |
Collapse
|
21
|
Does the Roller Pump Adjustment in Cardiopulmonary Bypass Settings Influence Hemolysis? Int J Artif Organs 2017; 40:118-122. [DOI: 10.5301/ijao.5000570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 11/20/2022]
Abstract
Introduction Roller pumps are widely used in procedures involving cardiopulmonary bypass (CPB) due to their ease of operation and maintenance, safety, and cost. Several studies in the literature have compared the use of roller pumps with centrifugal pumps, but the influence of the roller pump adjustment on hemolysis has been poorly explored. Methods Measurements of hemolysis rates were carried out in 86 patients. The pump was adjusted by the dynamic calibration method, which was performed by an auxiliary device, and the patients were grouped according to the pump calibration: Group 1 (n = 20) 75 mmHg; Group 2 (n = 24) 150 mmHg; Group 3 (n = 22) 300 mmHg and Group 4 (n = 21) 450 mmHg. The hemolysis rates were measured at 4 different times during CPB (TO: before the surgical procedure; T1: 5 minutes after the start of CPB; T2: 30 minutes of CPB; and T3: 5 minutes after the CPB procedure). Hemolysis rates were calculated between the time intervals T0–T1, T1–T2, and T0–T3. Results No difference in hemolysis rates was observed between the groups (p>0.31). During the first 5 minutes of CPB, hemolysis represented 35.5% of the total hemolysis and no significant difference was found between groups (p>0.60). Conclusions Calibration of roller pumps by the dynamic method did not influence the hemolysis rates. Additionally, the hemolysis during the first 5 minutes of CPB accounted for ∼1/3 of the total hemolysis.
Collapse
|
22
|
Prevalence of hemolysis and metabolic acidosis in patients with circulatory failure supported with extracorporeal life support: a marker for survival? Eur J Heart Fail 2017; 19 Suppl 2:110-116. [DOI: 10.1002/ejhf.854] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 03/27/2017] [Accepted: 04/01/2017] [Indexed: 12/30/2022] Open
|
23
|
Kaths JM, Cen JY, Chun YM, Echeverri J, Linares I, Ganesh S, Yip P, John R, Bagli D, Mucsi I, Ghanekar A, Grant DR, Robinson LA, Selzner M. Continuous Normothermic Ex Vivo Kidney Perfusion Is Superior to Brief Normothermic Perfusion Following Static Cold Storage in Donation After Circulatory Death Pig Kidney Transplantation. Am J Transplant 2017; 17:957-969. [PMID: 27647696 DOI: 10.1111/ajt.14059] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/07/2016] [Indexed: 01/25/2023]
Abstract
Hypothermic preservation is known to cause renal graft injury, especially in donation after circulatory death (DCD) kidney transplantation. We investigated the impact of cold storage (SCS) versus short periods of normothermic ex vivo kidney perfusion (NEVKP) after SCS versus prolonged, continuous NEVKP with near avoidance of SCS on kidney function after transplantation. Following 30 min of warm ischemia, kidneys were removed from 30-kg Yorkshire pigs and preserved for 16 h with (A) 16 h SCS, (B) 15 h SCS + 1 h NEVKP, (C) 8 h SCS + 8 h NEVKP, and (D) 16 h NEVKP. After contralateral kidney resection, grafts were autotransplanted and pigs followed up for 8 days. Perfusate injury markers such as aspartate aminotransferase and lactate dehydrogenase remained low; lactate decreased significantly until end of perfusion in groups C and D (p < 0.001 and p = 0.002). Grafts in group D demonstrated significantly lower serum creatinine peak when compared to all other groups (p < 0.001) and 24-h creatinine clearance at day 3 after surgery was significantly higher (63.4 ± 19.0 mL/min) versus all other groups (p < 0.001). Histological assessment on day 8 demonstrated fewer apoptotic cells in group D (p = 0.008). In conclusion, prolonged, continuous NEVKP provides superior short-term outcomes following DCD kidney transplantation versus SCS or short additional NEVKP following SCS.
Collapse
Affiliation(s)
- J M Kaths
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of General, Visceral, and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - J Y Cen
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Y M Chun
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - J Echeverri
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - I Linares
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - S Ganesh
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - P Yip
- Laboratory Medicine & Pathobiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - R John
- Laboratory Medicine & Pathobiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Bagli
- Departments of Surgery (Urology) & Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - I Mucsi
- Multi Organ Transplant Program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - A Ghanekar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - D R Grant
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - L A Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - M Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
24
|
Deshpande S, Maher K, Morales D. Mechanical circulatory support in children: Challenges and opportunities. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
25
|
Extracorporeal life support as a bridge to heart transplantation: importance of organ failure in recipient selection. ASAIO J 2016; 61:139-43. [PMID: 25396273 DOI: 10.1097/mat.0000000000000171] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We investigated the utility of comprehensive scoring systems for organ failure compared with the duration of extracorporeal life support (ECLS) in predicting survival after heart transplantation. From November 2004 to August 2013, 25 adult patients ultimately underwent heart transplantation while on ECLS. We did not include patients who were younger than 18 years old or patients with extracorporeal ventricular assist devices. Seven patients (28%) died within 1 year after transplantation. The areas under the curve (receiver operating characteristics (ROC), optimal cut-off value) of the sequential organ-failure assessment and the model for end-stage liver disease score modified by the United Network for Organ Sharing scores were 0.794 (13) and 0.825 (24), respectively. In multivariate analysis, the model for end-stage liver disease score modified by the United Network for Organ Sharing score was independently prognostic regardless of the duration of ECLS and sequential organ-failure assessment score.
Collapse
|
26
|
Popkirov S, Schlegel U, Skodda S. Is postoperative encephalopathy with choreoathetosis an acquired form of neuroacanthocytosis? Med Hypotheses 2016; 89:21-3. [PMID: 26968902 DOI: 10.1016/j.mehy.2016.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/01/2016] [Indexed: 12/01/2022]
Abstract
Postoperative encephalopathy with choreoathetosis ("postpump chorea") is a rare complication of open-heart surgery and, in particular, the employment of a cardiopulmonary bypass pump. It almost exclusively occurs in young children. While risk factors and the underlying histopathology have been identified, the pathogenesis of postpump chorea, crucially, remains largely unknown. Transient cerebral hypoperfusion associated with cardiopulmonary bypass is considered a likely candidate mechanism, but the evidence is insufficient and inconclusive. It is hypothesized in this article, that postpump chorea may be caused by mechanical trauma to red blood cells and resulting acanthocytosis. These dysfunctional erythrocytes could then lead to damage to the globus pallidus and disease development akin to that presumed in neuroacanthocytosis. In patients with neuroacanthocytosis an association between acanthocytosis and basal ganglia pathology has been suggested. To test the mechanism hypothesized here, the effects of cardiopulmonary bypass on erythrocyte morphology and function could be systematically tested in children undergoing cardiac surgery. Ideally, the extent of erythrocyte damage could be correlated with the risk of developing postpump chorea. Finally, if the proposed hypothesis is supported by empirical findings, efforts to reduce blood cell damage during extracorporeal circulation in children might prevent this devastating complication.
Collapse
Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Germany.
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Germany
| | - Sabine Skodda
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Germany
| |
Collapse
|
27
|
[Veno-arterial extracorporeal membrane oxygenation. Indications, limitations and practical implementation]. Anaesthesist 2015; 63:625-35. [PMID: 25074647 DOI: 10.1007/s00101-014-2362-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Due to the technical advances in pumps, oxygenators and cannulas, veno-arterial extracorporeal membrane oxygenation (va-ECMO) or extracorporeal life support (ECLS) has been widely used in emergency medicine and intensive care medicine for several years. An accepted indication is peri-interventional cardiac failure in cardiac surgery (postcardiotomy low cardiac output syndrome). Furthermore, especially the use of va-ECMO for other indications in critical care medicine, such as in patients with severe sepsis with septic cardiomyopathy or in cardiopulmonary resuscitation has tremendously increased. The basic indications for va-ECMO are therapy refractory cardiac or cardiopulmonary failure. The fundamental purpose of va-ECMO is bridging the function of the lungs and/or the heart. Consequently, this support system does not represent a causal therapy by itself; however, it provides enough time for the affected organ to recover (bridge to recovery) or for the decision for a long-lasting organ substitution by a ventricular assist device or by transplantation (bridge to decision). Although the outcome for bridged patients seems to be favorable, it should not be forgotten that the support system represents an invasive procedure with potentially far-reaching complications. Therefore, the initiation of these systems needs a professional and experienced (interdisciplinary) team, sufficient resources and an individual approach balancing the risks and benefits. This review gives an overview of the indications, complications and contraindications for va-ECMO. It discusses its advantages in organ transplantation and transport of critically ill patients. The reader will learn the differences between peripheral and central cannulation and how to monitor and manage va-ECMO.
Collapse
|
28
|
Platelet-derived microparticles generated by neonatal extracorporeal membrane oxygenation systems. ASAIO J 2015; 61:37-42. [PMID: 25303795 DOI: 10.1097/mat.0000000000000164] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Current anticoagulation strategies do not eliminate thromboembolic stroke or limb loss during neonatal extracorporeal membrane oxygenation (ECMO), a form of cardiopulmonary bypass (CPB). In adults, CPB surgery generates prothrombotic platelet-derived microparticles (PMPs), submicron membrane vesicles released from activated platelets. However, information on PMP generation in neonatal ECMO systems is lacking. The objective of this study was to compare PMP generation in five different neonatal ECMO systems, using a simulated circuit with swine blood at 300 ml/min for 4 hours. Systems were composed of both newer components (centrifugal pump and hollow-fiber oxygenator) and traditional components (roller-head pump and silicone membrane oxygenator). Free plasma hemoglobin levels were measured as an indicator of hemolysis and flow cytometry-measured PMP. Hemolysis generated in all ECMO systems was similar to that observed in noncirculated static blood (p = 0.48). There was no difference in net PMP levels between different oxygenators with a given pump. In contrast, net PMP generation in ECMO systems with a centrifugal pump was at least 2.5 times greater than in roller-head pump systems. This was significant when using either a hollow-fiber (p < 0.005) or a silicone membrane (p < 0.05) oxygenator. Future studies are needed to define the relationship between pump-generated PMP and thrombosis.
Collapse
|
29
|
Omar HR, Mirsaeidi M, Socias S, Sprenker C, Caldeira C, Camporesi EM, Mangar D. Plasma Free Hemoglobin Is an Independent Predictor of Mortality among Patients on Extracorporeal Membrane Oxygenation Support. PLoS One 2015; 10:e0124034. [PMID: 25902047 PMCID: PMC4406730 DOI: 10.1371/journal.pone.0124034] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/02/2015] [Indexed: 11/17/2022] Open
Abstract
Background Hemolysis is common in all extracorporeal circuits as evident by the elevated plasma free hemoglobin (PFHb) level. We investigated whether increased hemolysis during extracorporeal membrane oxygenation (ECMO) is an independent mortality predictor. Methods We performed a retrospective observational study of consecutive subjects who received ECMO at a tertiary care facility from 2007-2013 to investigate independent predictors of in-hospital mortality. We examined variables related to patient demographics, comorbidities, markers of hemolysis, ECMO characteristics, transfusion requirements, and complications. 24-hour PFHb> 50 mg/dL was used as a marker of severe hemolysis. Results 154 patients received ECMO for cardiac (n= 115) or pulmonary (n=39) indications. Patients’ mean age was 51 years and 75.3% were males. Compared to nonsurvivors, survivors had lower pre-ECMO lactic acid (p=0.026), lower 24-hour lactic acid (p=0.023), shorter ECMO duration (P=0.01), fewer RBC transfusions on ECMO (p=0.008) and lower level of PFHb 24-hours post ECMO implantation (p=0.029). 24-hour PFHb> 50 mg/dL occurred in 3.9 % versus 15.5% of survivors and nonsurvivors, respectively, p=0.002. A Cox proportional hazard analysis identified PFHb> 50 mg/dL 24-hours post ECMO as an independent predictor of mortality (OR= 3.4, 95% confidence interval: 1.3 – 8.8, p= 0.011). Conclusion PFHb> 50 mg/dL checked 24-hour post ECMO implantation is a useful tool to predict mortality. We propose the routine checking of PFHb 24-hours after ECMO initiation for early identification and treatment of the cause of hemolysis.
Collapse
Affiliation(s)
- Hesham R Omar
- Department of Internal Medicine, Mercy Medical Center, Clinton, Iowa, United States of America
| | - Mehdi Mirsaeidi
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Stephanie Socias
- Department of Research, Florida Gulf-to-Bay Anesthesiology Associates, Tampa, Florida, United States of America
| | - Collin Sprenker
- Department of Research, Florida Gulf-to-Bay Anesthesiology Associates, Tampa, Florida, United States of America
| | - Christiano Caldeira
- Department of Cardiothoracic Surgery, Florida Advanced Cardiothoracic Surgery, Tampa, Florida, United States of America
| | - Enrico M Camporesi
- University of South Florida, FGTBA and TEAMHealth, Tampa, Florida, United States of America
| | - Devanand Mangar
- Department of Anesthesia, Tampa General Hospital, FGTBA, TEAMHealth, Tampa, Florida, United States of America
| |
Collapse
|
30
|
Abstract
The use of Extracorporeal Life Support (ECLS) in children and adults has markedly increased during the past few years with over 4000 patients placed on ECLS every year in over 200 centers. This article focuses on updates to the physiology and mechanics of ECLS with use of magnetically levitated centrifugal pumps, hollow-fiber gas-exchange devices, and bi-caval dual-lumen catheters. We also explore controversies in management including indications, cannulation approaches, renal replacement, monitoring of anticoagulation, early ambulation, and termination of ECLS. Finally, we present changes in the systems that provide ECLS including the single-provider model and regionalization of care.
Collapse
Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
31
|
Xie A, Phan K, Tsai YC, Yan TD, Forrest P. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a meta-analysis. J Cardiothorac Vasc Anesth 2014; 29:637-45. [PMID: 25543217 DOI: 10.1053/j.jvca.2014.09.005] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the effect of extracorporeal membrane oxygenation (ECMO) on survival and complication rates in adults with refractory cardiogenic shock or cardiac arrest. DESIGN Meta-analysis. SETTING University hospitals. PARTICIPANTS One thousand one hundred ninety-nine patients from 22 observational studies. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Observational studies published from the year 2000 onwards, examining at least 10 adult patients who received ECMO for refractory cardiogenic shock or cardiac arrest were included. Pooled estimates with 95% confidence intervals were calculated based on the Freeman-Tukey double-arcsine transformation and DerSimonian-Laird random-effect model. Survival to discharge was 40.2% (95% confidence intervals [CI], 33.9-46.7), while survival at 3, 6, and 12 months was 55.9% (95% CI, 41.5-69.8), 47.6% (95% CI, 25.4-70.2), and 54.4% (95% CI, 36.6-71.7), respectively. Survival up to 30 days was higher in cardiogenic shock patients (52.5%, 95% CI, 43.7%-61.2%) compared to cardiac arrest (36.2%, 95% CI, 23.1%-50.4%). Concurrently, complication rates were particularly substantial for neurologic deficits (13.3%, 95% CI, 8.3-19.3), infection (25.1%, 95%CI, 15.9-35.5), and renal impairment (47.4%, 95% CI, 30.2-64.9). Significant heterogeneity was detected, although its levels were similar to previous meta-analyses that only examined short-term survival to discharge. CONCLUSIONS Venoarterial ECMO can improve short-term survival in adults with refractory cardiogenic shock or cardiac arrest. It also may provide favorable long-term survival at up to 3 years postdischarge. However, ECMO also is associated with significant complication rates, which must be incorporated into the risk-benefit analysis when considering treatment. These findings require confirmation by large, adequately controlled and standardized trials with long-term follow-up.
Collapse
Affiliation(s)
- Ashleigh Xie
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Kevin Phan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Yi-Chin Tsai
- Department of Cardiothoracic Surgery, Prince Charles Hospital, Brisbane, Australia
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Department of Cardiothoracic Surgery; University of Sydney, Sydney, Australia.
| | - Paul Forrest
- Cardiothoracic Anesthesia and Perfusion, Royal Prince Alfred Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| |
Collapse
|
32
|
Abstract
Microfluidic or microchannel artificial lungs promise to enable a new class of truly portable, therapeutic artificial lungs through feature sizes and blood channel designs that closely mimic those found in their natural counterpart. These new artificial lungs could potentially: 1) have surface areas and priming volumes that are a fraction of current technologies thereby decreasing device size and reducing the foreign body response; 2) contain blood flow networks in which cells and platelets experience pressures, shear stresses, and branching angles that copy those in the human lung thereby improving biocompatibility; 3) operate efficiently with room air, eliminating the need for gas cylinders and complications associated with hyperoxemia; 4) exhibit biomimetic hydraulic resistances, enabling operation with natural pressures and eliminating the need for blood pumps; and, 5) provide increased gas exchange capacity enabling respiratory support for active patients. This manuscript reviews recent research efforts in microfluidic artificial lungs targeted at achieving the advantages above, investigates the ultimate performance and scaling limits of these devices using a proven mathematical model, and discusses the future challenges that must be overcome in order for microfluidic artificial lungs to be applied in the clinic. If all of these promising advantages are realized and the remaining challenges are met, microfluidic artificial lungs could revolutionize the field of pulmonary rehabilitation.
Collapse
|
33
|
Ventetuolo CE, Muratore CS. Extracorporeal life support in critically ill adults. Am J Respir Crit Care Med 2014; 190:497-508. [PMID: 25046529 PMCID: PMC4214087 DOI: 10.1164/rccm.201404-0736ci] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/13/2014] [Indexed: 12/18/2022] Open
Abstract
Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.
Collapse
Affiliation(s)
- Corey E. Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep, Rhode Island Hospital, Departments of Medicine and Health Services, Policy, and Practice, and
| | - Christopher S. Muratore
- Division of Pediatric Surgery, Hasbro Children’s Hospital, Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| |
Collapse
|
34
|
Rehder KJ, Turner DA, Bonadonna D, Walczak RJ, Rudder RJ, Cheifetz IM. Technological advances in extracorporeal membrane oxygenation for respiratory failure. Expert Rev Respir Med 2014; 6:377-84. [DOI: 10.1586/ers.12.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
35
|
Bottrell S, Bennett M, Augustin S, Thuys C, Schultz B, Horton A, Horton S. A comparison study of haemolysis production in three contemporary centrifugal pumps. Perfusion 2014; 29:411-6. [PMID: 24406272 DOI: 10.1177/0267659113509000] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One challenge in providing extracorporeal circulation is to supply optimal flow while minimising adverse effects, such as haemolysis. To determine if the recent generation constrained vortex pumps with their inherent design improvements would lead to reduced red cell trauma, we undertook a study comparing three devices. Utilizing a simulated short-term ventricular assist circuit primed with whole human blood, we examined changes in plasma free haemoglobin values over a six-day period. The three pumps investigated were the Maquet Rotaflow, the Levitronix PediVAS and the Medos Deltastream DP3.This study demonstrated that all three pumps produced low levels of haemolysis and are suitable for use in a clinical environment. The Levitronix PediVAS was significantly less haemolytic than either the Rotaflow (p<0.05) or the DP3 (p<0.05). There was no significant difference in plasma free haemoglobin between the Rotaflow and the DP3 (p=0.71).
Collapse
Affiliation(s)
- S Bottrell
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - M Bennett
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - S Augustin
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - C Thuys
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - B Schultz
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - A Horton
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - S Horton
- Perfusion Department, Royal Children's Hospital, Melbourne, Victoria, Australia Department of Paediatrics, Melbourne University, Melbourne, Victoria, Australia
| |
Collapse
|
36
|
Palanzo DA, Baer LD, El-Banayosy A, Wang S, Ündar A, Pae WE. Choosing a Pump for Extracorporeal Membrane Oxygenation in the USA. Artif Organs 2014; 38:1-4. [DOI: 10.1111/aor.12215] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David A. Palanzo
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital; Hershey PA USA
| | - Larry D. Baer
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital; Hershey PA USA
| | - Aly El-Banayosy
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital; Hershey PA USA
| | - Shigang Wang
- Departments of Pediatrics, Surgery and Bioengineering, Pediatric Cardiovascular Research Center; Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital; Hershey PA USA
| | - Akif Ündar
- Departments of Pediatrics, Surgery and Bioengineering, Pediatric Cardiovascular Research Center; Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital; Hershey PA USA
| | - Walter E. Pae
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital; Hershey PA USA
| |
Collapse
|
37
|
Lafçı G, Budak AB, Yener AÜ, Cicek OF. Use of Extracorporeal Membrane Oxygenation in Adults. Heart Lung Circ 2014; 23:10-23. [DOI: 10.1016/j.hlc.2013.08.009] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
|
38
|
Palanzo DA, El-Banayosy A, Stephenson E, Brehm C, Kunselman A, Pae WE. Comparison of hemolysis between CentriMag and RotaFlow rotary blood pumps during extracorporeal membrane oxygenation. Artif Organs 2013; 37:E162-6. [PMID: 23981131 DOI: 10.1111/aor.12158] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this investigation was to compare the hemolysis levels for patients on extracorporeal membrane oxygenation (ECMO) incorporating two different rotary blood pumps (CentriMag [CMAG] and RotaFlow [RF]) in identical circuits otherwise. The difference between the two pumps is the cost. One is 20-30 times less expensive than the other. A retrospective analysis of all patients placed on ECMO from June 2008 through May 2012 was done to evaluate hemolysis. Daily plasma hemoglobin (pHb), lactate dehydrogenase (LDH), and lactate levels were collected on all patients. Values were compared between those patients who received a CMAG and those who received an RF. Patients had to be on ECMO for more than 2 days to be included in the study. Linear mixed effects models were fit to the data to assess differences over time for each continuous outcome. Forty patients were placed on ECMO incorporating CMAG, whereas 40 patients received an RF. There were no significant statistical differences between CMAG and RF groups when comparing days on support (8.7 ± 5.0; 8.4 ± 5.7), age (44.8 ± 18.3; 46.1 ± 16.0), body surface area (2.03 ± 0.36; 1.96 ± 0.31), gender (male: 58%, female: 42%; male: 55%, female: 45%), etiology, type of support (veno-arterial [VA)]: 78%, veno-venous [VV)]: 22%; VA: 82%, VV: 18%) and pre-ECMO LDH levels (4004.0 ± 3583.2; 3603.7 ± 3354.1). There were also no significant differences between the CMAG and RF groups when comparing the mean values for daily pHb levels (5.7 ± 3.6; 5.7 ± 4.2), lactate levels (2.8 ± 1.9; 3.0 ± 2.1), and LDH levels (2656.3 ± 1606.8; 2688.6 ± 1726.1) or daily lactate, LDH, and pHb levels for the first 10 days of support. From our investigation, there is no difference between the CMAG and the RF blood pumps in regard to the creation of hemolysis during ECMO. The difference in cost of the devices does not correlate with the performance and outcomes.
Collapse
Affiliation(s)
- David A Palanzo
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | | | | | | | | | | |
Collapse
|
39
|
Pediatric ECMO outcomes: comparison of centrifugal versus roller blood pumps using propensity score matching. ASAIO J 2013; 59:145-51. [PMID: 23438777 DOI: 10.1097/mat.0b013e31828387cd] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Centrifugal blood pumps are being increasingly utilized in children supported with extracorporeal membrane oxygenation (ECMO). Our aim was to determine if survival and ECMO-related morbidities in children supported with venoarterial (VA) ECMO differed by blood pump type.Children aged less than 18 years who underwent VA ECMO support from 2007 to 2009 and reported to the Extracorporeal Life Support Organization registry were propensity score matched (Greedy 1:1 matching) using pre-ECMO characteristics.A total of 2,656 (centrifugal = 2,231, roller = 425) patients were identified and 548 patients (274 per pump type) were included in the propensity score-matched cohort. Children supported with centrifugal pumps had increased odds of hemolysis (odds ratio [OR], 4.03 95% confidence interval [CI], 2.37-6.87), hyperbilirubinemia (OR, 5.48; 95% CI, 2.62-11.49), need for inotropic support during ECMO (OR, 1.54; 95% CI, 1.09-2.17), metabolic alkalosis (blood pH > 7.6) during ECMO (OR, 3.13; 95% CI, 1.49-6.54), and acute renal failure (OR, 1.61; 95% CI, 1.10-2.39). Survival to hospital discharge did not differ by pump type.In a propensity score-matched cohort of pediatric ECMO patients, children supported with centrifugal pumps had increased odds of ECMO-related complications. There was no difference in survival between groups.
Collapse
|
40
|
Hayes D, Tobias JD, Kukreja J, Preston TJ, Yates AR, Kirkby S, Whitson BA. Extracorporeal life support for acute respiratory distress syndromes. Ann Thorac Med 2013; 8:133-41. [PMID: 23922607 PMCID: PMC3731854 DOI: 10.4103/1817-1737.114290] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 01/21/2023] Open
Abstract
The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure.
Collapse
Affiliation(s)
- Don Hayes
- Section of Pulmonary Medicine, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph D. Tobias
- Section of Anesthesiology, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco Medical Center, San Francisco, CA, USA
| | - Thomas J. Preston
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
| | - Andrew R. Yates
- Section of Cardiology, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stephen Kirkby
- Section of Pulmonary Medicine, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A. Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
41
|
Abstract
The extracorporeal membrane oxygenation circuit is made of a number of components that have been customized to provide adequate tissue oxygen delivery in patients with severe cardiac and/or respiratory failure for a prolonged period of time (days to weeks). A standard extracorporeal membrane oxygenation circuit consists of a mechanical blood pump, gas-exchange device, and a heat exchanger all connected together with circuit tubing. Extracorporeal membrane oxygenation circuits can vary from simple to complex and may include a variety of blood flow and pressure monitors, continuous oxyhemoglobin saturation monitors, circuit access sites, and a bridge connecting the venous access and arterial infusion limbs of the circuit. Significant technical advancements have been made in the equipment available for short- and long-term extracorporeal membrane oxygenation applications. Contemporary extracorporeal membrane oxygenation circuits have greater biocompatibility and allow for more prolonged cardiopulmonary support time while minimizing the procedure-related complications of bleeding, thrombosis, and other physiologic derangements, which were so common with the early application of extracorporeal membrane oxygenation. Modern era extracorporeal membrane oxygenation circuitry and components are simpler, safer, more compact, and can be used across a wide variety of patient sizes from neonates to adults.
Collapse
Affiliation(s)
- Laurance Lequier
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
| | | | | | | |
Collapse
|
42
|
Aboud A, Liebing K, Börgermann J, Ensminger S, Zittermann A, Renner A, Hakim-Meibodi K, Gummert J. Excessive negative venous line pressures and increased arterial air bubble counts during miniaturized cardiopulmonary bypass: an experimental study comparing miniaturized with conventional perfusion systems. Eur J Cardiothorac Surg 2013; 45:69-74. [PMID: 23666376 DOI: 10.1093/ejcts/ezt257] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Miniaturized cardiopulmonary bypass (MCPB) is increasingly used in cardiac surgery, because it can lower clinically significant complications such as systemic inflammatory response, haemolysis and high transfusion requirements. A limitation of MCPB is the risk of excessive negative pressure in the venous line during volume depletion, probably leading to gaseous microembolism. METHODS In an experimental study with 24 pigs, we compared conventional open cardiopulmonary bypass (CCPB group, n = 11) with MCPB (n = 13). The same pump and identical tubing materials were used in both groups. Primary endpoints were pressure values in the venous line and the right atrium as well as the amount of air bubbles >500 µm. Secondary endpoints were biochemical parameters of systemic inflammatory response, ischaemia, haemodilution and haemolysis. RESULTS Nearly 20% of venous pressure values were below -150 mmHg and approximately 10% of the right atrial pressure values were below -100 mmHg in the MCPB group, during the experiment. No such low values were observed in the CCPB group. In addition, the number of large arterial air bubbles was higher in the MCPB group compared with the CCPB group (mean ± standard deviation [SD]: 13 444 ± 5709 vs 0.9 ± 0.6, respectively; P < 0.001). Bubble volume was also significantly larger during MCPB compared with CCPB (mean ± SD: 1522 ± 654 vs 4.1 ± 2.5 µl, respectively; P < 0.001). Blood levels of interleukin-6, free haemoglobin and creatine kinase were significantly higher in the CCPB group compared with the MCPB group. CONCLUSIONS Despite the benefits of MCPB regarding systemic inflammatory response and haemolysis, this technique is associated with excessive negative venous line pressures and a significant increase in the number and volume of arterial air bubbles compared with CCPB. Mini-perfusion systems and the management of MCPB require further refinements to avoid such adverse effects.
Collapse
Affiliation(s)
- Anas Aboud
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Vicente R, Moreno I, Soria A, Ramos F, Torregrosa S. Oxigenador de membrana extracorpóreo en el trasplante pulmonar. Med Intensiva 2013; 37:110-5. [DOI: 10.1016/j.medin.2012.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 06/24/2012] [Accepted: 06/28/2012] [Indexed: 10/27/2022]
|
44
|
Barrett CS, Jaggers JJ, Cook EF, Graham DA, Rajagopal SK, Almond CS, Seeger JD, Rycus PT, Thiagarajan RR. Outcomes of neonates undergoing extracorporeal membrane oxygenation support using centrifugal versus roller blood pumps. Ann Thorac Surg 2012; 94:1635-41. [PMID: 22921236 DOI: 10.1016/j.athoracsur.2012.06.061] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 06/25/2012] [Accepted: 06/26/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Advances in centrifugal blood pump technology have led to increased use of centrifugal pumps in extracorporeal membrane oxygenation (ECMO) circuits. Their efficacy and safety in critically ill neonates remains unknown. Blood cell trauma leading to hemolysis may result in end-organ injury in critically ill neonates receiving centrifugal pump ECMO. We hypothesized that neonates undergoing ECMO support using centrifugal pumps were at increased odds of hemolysis and subsequent end-organ injury. METHODS Children 30 days of age or younger who received support with venoarterial ECMO and were reported to the Extracorporeal Life Support Registry during 2007 to 2009 underwent propensity score matching (Greedy matching 1:1) using pre-ECMO support characteristics. RESULTS A total of 1,592 neonates receiving ECMO (centrifugal pump = 163 and roller pump = 1,492) were identified. Significant differences in demographic, presupport, and cannulation variables were present before matching. One hundred seventy-six neonates who were supported using either centrifugal (n = 88) or roller pumps (n = 88) were matched using propensity scoring. No significant differences in demographic, presupport, or cannulation variables were present after matching. Neonates undergoing support using centrifugal pumps had increased odds of hemolysis (odds ratio [OR], 7.7 [2.8-21.2]), hyperbilirubinemia (OR, 20.8 [2.7-160.4]), hypertension (OR, 3.2 [1.3-8.0]), and acute renal failure (OR, 2.4 [1.1-5.6]). Survival to discharge was not different between pump types. CONCLUSIONS Use of ECMO using centrifugal pumps is associated with increased odds of hemolysis that likely contributes to other end-organ injury. Research into the optimal use of centrifugal pumps and strategies to prevent support-related complications need to be investigated.
Collapse
Affiliation(s)
- Cindy S Barrett
- Department of Cardiology, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC. Cerebral and Lower Limb Near-Infrared Spectroscopy in Adults on Extracorporeal Membrane Oxygenation. Artif Organs 2012; 36:659-67. [DOI: 10.1111/j.1525-1594.2012.01496.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
46
|
Hemolytic and thrombocytopathic characteristics of extracorporeal membrane oxygenation systems at simulated flow rate for neonates. Pediatr Crit Care Med 2012; 13:e255-61. [PMID: 22596067 PMCID: PMC3477222 DOI: 10.1097/pcc.0b013e31823c98ef] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE A state-of-the-art centrifugal pump combined with hollow-fiber oxygenator for extracorporeal membrane oxygenation has potential advantages such as smaller priming volumes and decreased potential to cause tubing rupture as compared with the traditional roller head/silicone membrane systems. Adoption of these state-of-the-art systems has been slow in neonates as a result of past evidence of severe hemolysis that may lead to renal failure and increased mortality. Extracorporeal systems have also been linked to platelet dysfunction, a contributing factor toward intracranial hemorrhage, a leading cause of infant morbidity. Little data exist comparing the centrifugal systems with the roller systems in terms of hemolysis and platelet aggregation at low flow rates commonly used in neonatal extracorporeal membrane oxygenation. DESIGN Prospective, comparative laboratory study. SETTING University research laboratory. SUBJECTS Centrifugal pump, roller pump, hollow-fiber oxygenator, and silicone membrane oxygenator. INTERVENTIONS Comparative study using two pumps, the centrifugal Jostra Rotaflow (Maquet, Wayne, NJ) and the roller-head (Jostra, Maquet, Wayne, NJ), and two oxygenators, polymethlypentene Quadrox-D (Maquet) and silicone membrane (Medtronic, Minneapolis, MN). Five test runs of four circuit combinations were examined for hemolysis and platelet aggregation during 6 hrs of continuous use in a simulated in vitro extracorporeal membrane oxygenation circuit circulating whole swine blood at 300 mL/min. MEASUREMENTS AND MAIN RESULTS Hemolysis was assessed by spectrophometric measurement of plasma-free hemoglobin. Platelet aggregation was evaluated using monoclonal CD61 antibody fluorescent flow cytometry profiles. All of the extracorporeal membrane oxygenation systems created plasma-free hemoglobin at a similar rate compared with static blood control. There was no difference in the mean normalized index of hemolysis of the centrifugal/hollow-fiber oxygenator system as compared with the roller-head/silicone membrane systems (0.0032 g/100 L vs. 0.0058 g/100 L, p ≥ .7). None of the extracorporeal membrane oxygenation systems had a significant increase in platelet aggregation above baseline. CONCLUSIONS In a low-flow neonatal environment, a state-of-the-art centrifugal pump combined with new fiber-type oxygenators appear to be safe in regard to hemolysis and platelet aggregation.
Collapse
|
47
|
|
48
|
Abstract
New technologies have become available to minimize the adverse events of extracorporeal devices. Link to these technological improvements ECMO in lung transplantation is currently essential. Bridging to lung transplantation changes to concepts avoiding the sequels mechanical ventilation and thereby offers improvement of lung recipients prior to the transplant procedure. Its use as hemodynamic and respiratory support during the lung transplant surgery can replace conventional Cardiopulmonary bypass. And finally, ECMO is sometimes the only alternative in the most severe forms of primary graft failure.
Collapse
Affiliation(s)
- E Sage
- Service de Chirurgie Thoracique et Transplantation Pulmonaire, Hôpital Foch, 40, rue Worth, 92151 Suresnes, France.
| |
Collapse
|
49
|
Sidebotham D, Allen SJ, McGeorge A, Ibbott N, Willcox T. Venovenous extracorporeal membrane oxygenation in adults: practical aspects of circuits, cannulae, and procedures. J Cardiothorac Vasc Anesth 2012; 26:893-909. [PMID: 22503344 DOI: 10.1053/j.jvca.2012.02.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Indexed: 01/19/2023]
Affiliation(s)
- David Sidebotham
- Cardiothoracic Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.
| | | | | | | | | |
Collapse
|
50
|
Sadahiro T, Oda S, Nakamura M, Hirayama Y, Watanabe E, Tateishi Y, Shinozaki K. Trends in and perspectives on extracorporeal membrane oxygenation for severe adult respiratory failure. Gen Thorac Cardiovasc Surg 2012; 60:192-201. [PMID: 22451141 DOI: 10.1007/s11748-011-0868-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Indexed: 10/28/2022]
Abstract
Various approaches such as ventilator management involving lung-protective ventilation, corticosteroids, prone positioning, and nitric oxide have failed to maintain sufficient lung oxygenation or appropriate ventilation competence in very severe acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) has been aggressively introduced for such patients, although in only a few institutions. The clinical usefulness of ECMO in a large-scale multicenter study (CESAR trial, 2009) and continued development/improvement of ECMO devices have facilitated performance of ECMO, with further increase in the number of institutions adopting ECMO therapy. Clinical usefulness of ECMO was documented in many cases of severe ARDS secondary to influenza A (H1N1) 2009 infection. ECMO requires establishment of an appropriate management system to minimize fatal complications (e.g., hemorrhage), which requires a multidisciplinary team. This, in combination with a new technique, interventional lung assist, will further extend the indications for ECMO. ECMO can be expected to gain importance as a respiratory support technique.
Collapse
Affiliation(s)
- Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuoku, Chiba, 260-8677, Japan.
| | | | | | | | | | | | | |
Collapse
|