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Lucchini A, Villa M, Giani M, Canzi S, Colombo S, Mapelli E, Mariani I, Rezoagli E, Foti G, Bellani G. Impact of new lighting technology versus traditional fluorescent bulbs on sedation and delirium in the ICU. Intensive Crit Care Nurs 2024; 86:103833. [PMID: 39299170 DOI: 10.1016/j.iccn.2024.103833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 08/07/2024] [Accepted: 09/05/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Critically ill patients frequently encounter disruptions in their circadian rhythms in the intensive care unit (ICU) environment. New lighting systems have been developed to enhance daytime light levels and to promote circadian alignment. OBJECTIVES To investigate the impact of implementing an innovative lighting technology that mimics natural light and reproduce the colour of the sky. DESIGN Prospective, observational, non-randomized comparative trial. ICU patients were exposed to either a cutting-edge lighting system based on new technology (intervention group) or a conventional lighting system using fluorescent bulbs (control group). SETTING An Italian intensive care unit with ten beds and five windowless rooms, thereby denying access to natural light. Three rooms had new lighting technology. MAIN OUTCOME MEASURES The two groups were compared to assess the prevalence or absence of delirium and the need for sedatives during ICU stay. The secondary aim was to assess the presence of anxiety, depression, and post-traumatic stress disorder in patients at 3, 6, and 12 months after ICU discharge. RESULTS 86 patients were included: 52 (60 %) in the intervention group and 34 (40 %) in the control group. Seventy-nine patients (82 %) were alive at ICU discharge. Fourteen patients (16 %) developed delirium (intervention group: n = 8 [15 %] vs. control group: n = 6 [18 %] in the control group, (P=0.781). The use of sedative drugs and neuromuscular blocking agents was similar in both the groups. No differences in the incidence of anxiety, depression, or post-traumatic stress disorders were observed among patients who underwent follow-up visits. CONCLUSIONS Compared to traditional fluorescent tube lighting, the innovative lighting system did not provide any significant benefit in reducing the frequency of delirium or the necessity for sedative medications. IMPLICATIONS FOR CLINICAL PRACTICE A single intervention, the use of lights that mimic sunny light and the sky, did not result in a statistically significant reduction in the incidence of delirium. Delirium has a multifactorial aetiology, necessitating interventions that are multifaceted and address different domains.
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Affiliation(s)
- Alberto Lucchini
- Direction of Health and Social Professions, General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza, University of Milano-Bicocca, Italy.
| | - Marta Villa
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marco Giani
- University of Milano-Bicocca and Department of Emergency and Intensive Care Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Sabrina Canzi
- Pneumology Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Sara Colombo
- General Intensive Care Unit, ASST GOM Niguarda, Milano, Italy
| | - Elisa Mapelli
- Genaral Intensive Care Unit, Policlinico di Monza, Monza, Italy
| | - Ilaria Mariani
- Genaral Intensive Care Unit, Policlinico di Monza, Monza, Italy.
| | - Emanuele Rezoagli
- University of Milano-Bicocca and Department of Emergency and Intensive Care Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Giuseppe Foti
- University of Milano-Bicocca and Department of Emergency and Intensive Care Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Giacomo Bellani
- Anesthesia and Critical Care Medicine of the University of Trento, Italy.
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Passarelli MT, Petit M, Garberi R, Lebreton G, Luyt CE, Pineton De Chambrun M, Chommeloux J, Hékimian G, Rezoagli E, Foti G, Combes A, Giani M, Schmidt M. Mechanical ventilation settings during weaning from venovenous extracorporeal membrane oxygenation. Ann Intensive Care 2024; 14:138. [PMID: 39230734 PMCID: PMC11374948 DOI: 10.1186/s13613-024-01359-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/02/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND The optimal timing of weaning from venovenous extracorporeal membrane oxygenation (VV ECMO) and its modalities have been rarely studied. METHODS Retrospective, multicenter cohort study over 7 years in two tertiary ICUs, high-volume ECMO centers in France and Italy. Patients with ARDS on ECMO and successfully weaned from VV ECMO were classified based on their mechanical ventilation modality during the sweep gas-off trial (SGOT) with either controlled mechanical ventilation or spontaneous breathing (i.e. pressure support ventilation). The primary endpoint was the time to successful weaning from mechanical ventilation within 90 days post-ECMO weaning. RESULTS 292 adult patients with severe ARDS were weaned from controlled ventilation, and 101 were on spontaneous breathing during SGOT. The 90-day probability of successful weaning from mechanical ventilation was not significantly different between the two groups (sHR [95% CI], 1.23 [0.84-1.82]). ECMO-related complications were not statistically different between patients receiving these two mechanical ventilation strategies. After adjusting for covariates, older age, higher pre-ECMO sequential organ failure assessment score, pneumothorax, ventilator-associated pneumonia, and renal replacement therapy, but not mechanical ventilation modalities during SGOT, were independently associated with a lower probability of successful weaning from mechanical ventilation after ECMO weaning. CONCLUSIONS Time to successful weaning from mechanical ventilation within 90 days post-ECMO was not associated with the mechanical ventilation strategy used during SGOT. Further research is needed to assess the optimal ventilation strategy during weaning off VV ECMO and its impact on short- and long-term outcomes.
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Affiliation(s)
- Maria Teresa Passarelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Matthieu Petit
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Roberta Garberi
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique-Hôpitaux de Paris, Thoracic and Cardiovascular Department, Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France
| | - Charles Edouard Luyt
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Marc Pineton De Chambrun
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Alain Combes
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Marco Giani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
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Müller-Wirtz LM, O'Gara B, Gama de Abreu M, Schultz MJ, Beitler JR, Jerath A, Meiser A. Volatile anesthetics for lung- and diaphragm-protective sedation. Crit Care 2024; 28:269. [PMID: 39217380 PMCID: PMC11366159 DOI: 10.1186/s13054-024-05049-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients.
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Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany
- Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Brian O'Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marcelo Gama de Abreu
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Division of Intensive Care and Resuscitation, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, New York-Presbyterian Hospital and Columbia University, New York, NY, USA
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany.
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Fumagalli B, Giani M, Bombino M, Fumagalli D, Merelli M, Chiesa G, Rona R, Bellani G, Rezoagli E, Foti G. Pressure Support Ventilation During Extracorporeal Membrane Oxygenation Support in Patients With Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00542. [PMID: 39116298 DOI: 10.1097/mat.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance (p = 0.02) and a reduction in pulmonary shunt fraction (p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures (p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.
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Affiliation(s)
- Benedetta Fumagalli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Giani
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Denise Fumagalli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Milena Merelli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gaia Chiesa
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Department of Medical Sciences, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari di Trento, Trento, Italy
| | - Emanuele Rezoagli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giuseppe Foti
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
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Contreras S, Giménez-Esparza Vich C, Caballero J. Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2024; 48:467-476. [PMID: 38862301 DOI: 10.1016/j.medine.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/16/2024] [Indexed: 06/13/2024]
Abstract
The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.
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Affiliation(s)
- Sofía Contreras
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | | | - Jesús Caballero
- Servicio de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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Alcántara Carmona S, Del Saz A, Contreras S, Riera J, Blandino A. Volatile sedation practices in patients with severe acute respiratory distress syndrome under VV-ECMO support. Intensive Care Med 2024; 50:1161-1163. [PMID: 38753268 DOI: 10.1007/s00134-024-07479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Sara Alcántara Carmona
- Intensive Care Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain.
| | - Ana Del Saz
- Intensive Care Department, Hospital Clínico Universitario Virgen de La Arrixaca, El Palmar, Murcia, Spain
| | - Sofía Contreras
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- SODIR, Vall d'Hebron Research Institute, Barcelona, Spain
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Aaron Blandino
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Lucchini A, Villa M, Giani M, Andreossi M, Alessandra V, Vigo V, Gatti S, Ferlicca D, Teggia Droghi M, Rezoagli E, Foti G, Pozzi M, Irccs San Gerardo Follow-Up Group. Long term outcome in patients treated with veno-venous extracorporeal membrane oxygenation: A prospective observational study. Intensive Crit Care Nurs 2024; 82:103631. [PMID: 38309144 DOI: 10.1016/j.iccn.2024.103631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Over the last few decades, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) support for severe respiratory failure has increased. AIM This study aimed to assess the long-term outcomes of patients treated with VV-ECMO for respiratory failure. METHODS We performed a single-centre prospective evaluation of patients on VV-ECMO who were successfully discharged from the intensive care unit of an Italian University Hospital between January 2018 and May 2021. The enrolled patients underwent follow-up evaluations at 6 and 12 months after ICU discharge. The follow-up team performed psychological and functional assessments using the following instruments: Hospital Anxiety and Depression Scale (HADS), Post-traumatic Stress Disorder Symptom Severity Scale (PTSS-10), Euro Quality Five Domains Five Levels (EQ-5L-5D), and 6-minute walk test. RESULTS We enrolled 33 patients who were evaluated at a follow-up clinic. The median patient age was 51 years (range: 45-58 years). The median duration of VV-ECMO support was 12 (9-19) days and the length of ICU stay was 23 (18-42) days. A HADS score higher than 14 was reported in 8 (24 %) and 7 (21 %) patients at the six- and twelve-month visit, respectively. PTSS-10 total score ≥ 35 points was present in three (9 %) and two (6 %) patients at the six- and twelve-month examination. The median EQ-5L-5D-VAS was respectively 80 (80-90) and 87.5 (70-95). The PTSS-10 score significantly decreased from six to 12 months in COVID-19 survivors (p = 0.024). CONCLUSIONS In this cohort of patients treated with VV-ECMO, cognitive and psychological outcomes were good and comparable to those of patients with Adult Respiratory Distress Syndrome (ARDS) managed without ECMO. IMPLICATIONS FOR CLINICAL PRACTICE The findings of this study confirm the need for long-term follow-up and rehabilitation programs for every ICU survivor after discharge. COVID-19 survivors treated with VV-ECMO had outcomes comparable to those reported in non-COVID patients.
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Affiliation(s)
- Alberto Lucchini
- Direction of health and social professions - General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Marta Villa
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Marco Giani
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Mara Andreossi
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Valentino Alessandra
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Veronica Vigo
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Stefano Gatti
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Daniela Ferlicca
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Maddalena Teggia Droghi
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza.
| | - Emanuele Rezoagli
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Giuseppe Foti
- General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza; University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy.
| | - Matteo Pozzi
- University of Milano-Bicocca, Via Pergolesi 33, Monza (MB), Italy; Cardiosurgical ICU Fondazione IRCCS San Gerardo dei Tintori - Monza.
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Lucchini A, Villa M, Maino C, Alongi F, Fiorica V, Lipani B, Ponzetta G, Vigo V, Rezoagli E, Giani M. The occurrence of pressure injuries and related risk factors in patients undergoing extracorporeal membrane oxygenation for respiratory failure: A retrospective single centre study. Intensive Crit Care Nurs 2024; 82:103654. [PMID: 38387296 DOI: 10.1016/j.iccn.2024.103654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Limited data is available regarding the incidence of pressure injuries in patients who have undergone Extracorporeal Membrane Oxygenation (ECMO), a life-saving technique that provides respiratory support for hypoxemia that does not respond to conventional treatment. AIM To assess the incidence of pressure injuries and identify the risk factors in Acute Respiratory Distress Syndrome patients receiving ECMO. METHODS A retrospective observational study utilizing prospectively collected data was performed in an Italian intensive care unit, between 1 January 2012 and 30 April 2022 enrolling all consecutive patients with Acute Respiratory Distress Syndrome who underwent ECMO. RESULTS One hundred patients were included in this study. 67 patients (67%) developed pressure injuries during their intensive care unit stay, with a median of 2 (1-3) sites affected. The subgroup of patients with pressure injuries was more hypoxic before ECMO implementation, received more frequent continuous renal replacement therapy and prone positioning, and showed prolonged ECMO duration, intensive care unit and hospital length of stay compared to patients without pressure injuries. The logistic model demonstrated an independent association between the pO2/FiO2 ratio prior to ECMO initiation, the utilization of the prone positioning during ECMO, and the occurrence of pressure injuries. CONCLUSIONS The incidence of pressure injuries was elevated in patients with Adult Respiratory Distress Syndrome who received ECMO. The development of pressure injuries was found to be independently associated with hypoxemia before ECMO initiation and the utilization of prone positioning during ECMO. IMPLICATIONS FOR CLINICAL PRACTICE Patients who require ECMO for respiratory failure are at a high risk of developing pressure injuries. To ensure optimal outcomes during ECMO implementation and treatment, it is vital to implement preventive measures and to closely monitor skin health in at-risk areas.
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Affiliation(s)
- Alberto Lucchini
- Direction of Health and Social Professions, General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza - University of Milano-Bicocca, Italy.
| | - Marta Villa
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Clara Maino
- Direction of Health and Social Professions, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Francesca Alongi
- Cardiologic Intensive Care Unit, ASST GOM Niguarda, Milano, Italy
| | | | - Barbara Lipani
- General ICU - A.O.U.I. Verona Policlinico G.B. Rossi, Italy
| | - Giuseppe Ponzetta
- Centro Sanitario Bregaglia - Pronto Soccorso, Promontogno, Svizzera, Switzerland.
| | - Veronica Vigo
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Marco Giani
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
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García-Montoto F, Paz-Martín D, Pestaña D, Soro M, Marcos Vidal JM, Badenes R, Suárez de la Rica A, Bardi T, Pérez-Carbonell A, García C, Cervantes JA, Martínez MP, Guerrero JL, Lorente JV, Veganzones J, Murcia M, Belda FJ. Guidelines for inhaled sedation in the ICU. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:90-111. [PMID: 38309642 DOI: 10.1016/j.redare.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/29/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.
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Affiliation(s)
- F García-Montoto
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain.
| | - D Paz-Martín
- UCI, Departamento de Anestesia y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - D Pestaña
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - M Soro
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - J M Marcos Vidal
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, Spain
| | - R Badenes
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain; UCI de Anestesia, Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Valencia, Valencia, Spain; INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | - A Suárez de la Rica
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
| | - T Bardi
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Pérez-Carbonell
- UCI Quirúrgica, Servicio de Anestesiología, UCI Quirúrgica y Unidad del Dolor, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - C García
- UCI Quirúrgica, Servicio de Anestesiología y Reanimación, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - J A Cervantes
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Torrecárdenas, Almería, Spain
| | - M P Martínez
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J L Guerrero
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Universidad de Málaga, Málaga, Spain; Instituto Biomédico de Málaga, Málaga, Spain
| | - J V Lorente
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - J Veganzones
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - M Murcia
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - F J Belda
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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10
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Pellet PL, Stevic N, Degivry F, Louis B, Argaud L, Guérin C, Cour M. Effects on mechanical power of different devices used for inhaled sedation in a bench model of protective ventilation in ICU. Ann Intensive Care 2024; 14:18. [PMID: 38285231 PMCID: PMC10825094 DOI: 10.1186/s13613-024-01245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/06/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Inhaled sedation during invasive mechanical ventilation in patients with acute respiratory distress syndrome (ARDS) has received increasing attention. However, inhaled sedation devices increase dead-space ventilation and an undesirable effect is the increase in minute ventilation needed to maintain CO2 removal. A consequence of raising minute ventilation is an increase in mechanical power (MP) that can promote lung injury. However, the effect of inhaled sedation devices on MP remains unknown. METHODS We conducted a bench study to assess and compare the effects of three devices delivering inhaled sevoflurane currently available in ICU (AnaConDa-50 mL (ANA-50), AnaConDa-100 mL (ANA-100), and MIRUS) on MP by using a test lung model set with three compliances (20, 40, and 60 mL/cmH2O). We simulated lung-protective ventilation using a low tidal volume and two levels of positive end-expiratory pressure (5 and 15 cmH2O) under ambient temperature and dry conditions. Following the insertion of the devices, either the respiratory rate or tidal volume was increased in 15%-steps until end-tidal CO2 (EtCO2) returned to the baseline value. MP was calculated at baseline and after EtCO2 correction using a simplified equation. RESULTS Following device insertion, the EtCO2 increase was significantly greater with MIRUS (+ 78 ± 13%) and ANA-100 (+ 100 ± 11%) than with ANA-50 (+ 49 ± 7%). After normalizing EtCO2 by adjusting minute ventilation, MP significantly increased by more than 50% with all inhaled sedation devices compared to controls. The lowest increase in MP was observed with ANA-50 (p < 0.05 versus ANA-100 and MIRUS). The Costa index, another parameter assessing the mechanical energy delivered to the lungs, calculated as driving pressure × 4 + respiratory rate, significantly increased by more than 20% in all experimental conditions. Additional experiments performed under body temperature, ambient pressure, and gas saturated with water vapor conditions, confirmed the main results with an increase in MP > 50% with all devices after normalizing EtCO2 by adjusting minute ventilation. CONCLUSION Inhaled sedation devices substantially increased MP in this bench model of protective ventilation, which might limit their benefits in ARDS.
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Affiliation(s)
- Pierre-Louis Pellet
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Neven Stevic
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Florian Degivry
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM 955 CNRS 7000, Créteil, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Claude Guérin
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France.
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France.
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11
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Lucchini A, Giani M, Bambi S. The long journey of an ECMO patient: Survival is not always recovery. Intensive Crit Care Nurs 2023; 79:103499. [PMID: 37541067 DOI: 10.1016/j.iccn.2023.103499] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Affiliation(s)
- Alberto Lucchini
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori - University of Milano-Bicocca, Monza, Italy.
| | - Marco Giani
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori - University of Milano-Bicocca, Monza, Italy
| | - Stefano Bambi
- Department of Health Sciences, University of Florence, Florence, Italy
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12
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Consales G, Cappellini I, Freschi B, Campiglia L, Parise M, Zamidei L. Sevoflurane sedation in COVID-19 acute respiratory distress syndrome: an observational study with a propensity score matching model. Front Med (Lausanne) 2023; 10:1267691. [PMID: 37780555 PMCID: PMC10540812 DOI: 10.3389/fmed.2023.1267691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction The management of severe COVID-19-induced acute respiratory distress syndrome (C-ARDS) often involves deep sedation. This study evaluated the efficacy of sevoflurane, a volatile anesthetic, as an alternative to traditional intravenous sedation in this patient population. Methods This single-center, retrospective cohort study enrolled 112 patients with C-ARDS requiring invasive mechanical ventilation. A propensity score matching model was utilized to pair 56 patients receiving sevoflurane sedation with 56 patients receiving intravenous sedation. The primary outcome was mortality, with secondary outcomes being changes in oxygenation (PaO2/FiO2 ratio), pulmonary compliance, and levels of D-Dimer, CRP, and creatinine. Results The use of sevoflurane was associated with a statistically significant reduction in mortality (OR 0.40, 95% CI 0.18-0.87, beta = -0.9, p = 0.02). In terms of secondary outcomes, an increase in the PaO2/FiO2 ratio and pulmonary static compliance was observed, although the results were not statistically significant. No significant differences were noted in the levels of D-Dimer, CRP, and creatinine between the two groups. Conclusion Our findings suggest an association between the use of sevoflurane and improved outcomes in C-ARDS patients requiring invasive mechanical ventilation. However, due to the single-center, retrospective design of the study, caution should be taken in interpreting these results, and further research is needed to corroborate these findings. The study offers promising insights into potential alternative sedation strategies in the management of severe C-ARDS.
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Affiliation(s)
- Guglielmo Consales
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Iacopo Cappellini
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Benedetta Freschi
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Laura Campiglia
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
| | - Maddalena Parise
- Anesthesia Unit, Castellanza Hospital, Multimedica Group, Milan, Italy
| | - Lucia Zamidei
- Department of Critical Care, Section of Anesthesiology and Critical Care Azienda USL Toscana Centro, Ospedale Santo Stefano, Prato, Italy
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Stallworth S, Ohman K, Schultheis J, Parish A, Erkanli A, Kim H, Rackley CR. Propofol-Associated Hypertriglyceridemia in Adults With Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:856-862. [PMID: 37172007 DOI: 10.1097/mat.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
The incidence and risk factors for propofol-associated hypertriglyceridemia (HTG) in patients receiving extracorporeal membrane oxygenation (ECMO) have not been evaluated. The purpose of this study was to determine the incidence and risk factors for propofol-associated HTG in patients with acute respiratory distress syndrome (ARDS) on ECMO. This retrospective, cohort study included 167 adults admitted to a medical intensive care unit (ICU) from July 1, 2013 to September 1, 2021, who received 24 hours of concurrent propofol and ECMO therapy. The primary outcome was the incidence of propofol-associated HTG. Secondary outcomes included HTG risk factors, time to development and resolution of HTG, and incidence of pancreatitis. HTG occurred in 58 (34.7%) patients. Patients with HTG had longer durations of ECMO (19 vs. 13 days, p < 0.001), longer ICU length of stay (26.5 vs. 23 days, p = 0.002), and higher in-hospital mortality (51.7 vs. 34.9%, p = 0.047). Baseline sequential organ failure assessment score was associated with an increased risk of developing HTG (hazard ratio [HR] = 1.19, 95% confidence interval [CI] = 1.09-1.30; p < 0.001). Propofol-associated HTG occurred in one-third of patients receiving ECMO for ARDS. Higher baseline illness severity and ECMO duration were associated with an increased risk of propofol-associated HTG.
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Affiliation(s)
| | - Kelsey Ohman
- From the Duke University Hospital, Durham, North Carolina
| | | | - Alice Parish
- From the Duke University Hospital, Durham, North Carolina
| | | | - Heewon Kim
- From the Duke University Hospital, Durham, North Carolina
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Gill B, Bartock JL, Damuth E, Puri N, Green A. Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation. Front Med (Lausanne) 2022; 9:1051468. [PMID: 36425104 PMCID: PMC9679515 DOI: 10.3389/fmed.2022.1051468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/19/2022] [Indexed: 08/15/2023] Open
Abstract
Volatile anesthetics have been described as a rescue therapy for patients with refractory status asthmaticus (SA), and the use of isoflurane for this indication has been reported since the 1980s. Much of the literature reports good outcomes when inhaled isoflurane is used as a rescue therapy for patients for refractory SA. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a mode of mechanical circulatory support that is usually employed as a potentially lifesaving intervention in patients who have high risk of mortality, primarily for underlying pulmonary pathology. VV ECMO is usually only considered in cases where patients gas exchange cannot be satisfactorily maintained by conventional therapy and mechanical ventilation strategies. We report the novel use of isoflurane delivered systemically as treatment for severe refractory SA in a patient on VV ECMO. A 51-year-old male with a history of asthma was transferred from another institution for management of severe SA. He was intubated at the referring hospital after failing non-invasive ventilation. Initial arterial blood gas (ABG) showed pH 7.21, partial pressure of carbon dioxide (PCO2) >95 mmHg, and partial pressure of oxygen (PaO2) 60 mmHg. VV ECMO was initiated on hospital day (HD) 1 due to refractory respiratory acidosis. After ECMO initiation, acid-base status improved, however, severe bronchospasm persisted and intrinsic positive end expiratory pressure (PEEP) was measured at 18 cm H2O. Systemic paralysis was employed, respiratory rate (RR) was reduced to 4 breaths per minute. This degree of bronchospasm did not allow for ECMO weaning. On HD 5, the patient received systemic isoflurane via the ECMO circuit for 20 h. The following morning, intrinsic PEEP was 4 cm H2O, and wheezing improved. He was decannulated from VV ECMO on HD 10 and extubated on HD 17. Inhaled isoflurane therapy in patients on VV ECMO for refractory SA has shown good results, but requires delivery of the medication via anesthesia ventilators. Our case highlights an effective alternative, systemic delivery of anesthetic via the ECMO circuit, as it is often difficult and dangerous to transport these patients to the operating room (OR) or have an intensive care unit (ICU) room adjusted to accommodate an anesthesia ventilator.
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Affiliation(s)
- Brendan Gill
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ, United States
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Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions. MEMBRANES 2021; 11:membranes11030172. [PMID: 33670987 PMCID: PMC7997339 DOI: 10.3390/membranes11030172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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