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Javidfar J, Zaaqoq AM, Labib A, Barnett AG, Hayanga JWA, Eschun G, Yamashita MH, Jacobs JP, Heinsar S, Suen JY, Fraser JF, Bassi GL, Arora RC, Peek GJ. Morbid obesity's impact on COVID-19 patients requiring venovenous extracorporeal membrane oxygenation: The covid-19 critical care consortium database review. Perfusion 2024; 39:702-712. [PMID: 36753684 PMCID: PMC9912044 DOI: 10.1177/02676591231156487] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Introduction: Obesity is associated with a worse prognosis in COVID-19 patients with acute respiratory distress syndrome (ARDS). Veno-venous (V-V) Extracorporeal Membrane Oxygenation (ECMO) can be a rescue option, however, the direct impact of morbid obesity in this select group of patients remains unclear.Methods: This is an observational study of critically ill adults with COVID-19 and ARDS supported by V-V ECMO. Data are from 82 institutions participating in the COVID-19 Critical Care Consortium international registry. Patients were admitted between 12 January 2020 to 27 April 2021. They were stratified based on Body Mass Index (BMI) at 40 kg/m2. The endpoint was survival to hospital discharge.Results: Complete data available on 354 of 401 patients supported on V-V ECMO. The characteristics of the high BMI (>40 kg/m2) and lower BMI (≤40 kg/m2) groups were statistically similar. However, the 'high BMI' group were comparatively younger and had a lower APACHE II score. Using survival analysis, older age (Hazard Ratio, HR 1.49 per-10-years, CI 1.25-1.79) and higher BMI (HR 1.15 per-5 kg/m2 increase, CI 1.03-1.28) were associated with a decreased patient survival. A safe BMI threshold above which V-V ECMO would be prohibitive was not apparent and instead, the risk of an adverse outcome increased linearly with BMI.Conclusion: In COVID-19 patients with severe ARDS who require V-V ECMO, there is an increased risk of death associated with age and BMI. The risk is linear and there is no BMI threshold beyond which the risk for death greatly increases.
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Affiliation(s)
- Jeffrey Javidfar
- Division of Cardiothoracic
Surgery, Department of Surgery, Emory School of
Medicine, USA
| | - Akram M Zaaqoq
- Department of Critical Care
Medicine, MedStar Washington Hospital
Center, Georgetown University, USA
| | - Ahmed Labib
- Medical Intensive Care
Unit, Department of Medicine, Hamad General Hospital, Qatar
| | - Adrian G Barnett
- School of Public Health & Social
Work, Queensland University of
Technology, Australia
| | - JW Awori Hayanga
- Department of Cardiovascular &
Thoracic Surgery, West Virginia
University, USA
| | - Greg Eschun
- Department of Medicine, Section of Critical Care
Medicine, Max Rady College of
Medicine, University of Manitoba, Canada
| | - Michael H Yamashita
- Department of Surgery, Section of Cardiac
Surgery, Max Rady College of
Medicine, University of Manitoba, Canada
| | - Jeffrey P Jacobs
- Congenital Heart Center, Department of Surgery, University of Florida, USA
| | - Silver Heinsar
- Critical Care Research
Group, The Prince Charles
Hospital, and University of
Queensland, Australia
| | - Jacky Y Suen
- Critical Care Research
Group, The Prince Charles
Hospital, and University of
Queensland, Australia
| | - John F Fraser
- Critical Care Research
Group, The Prince Charles
Hospital, and University of
Queensland, Australia
| | - Gianluigi Li Bassi
- Critical Care Research
Group, The Prince Charles
Hospital, and University of
Queensland, Australia
| | - Rakesh C Arora
- Heart &Vascular
Institute, Division of Cardiac
Surgery, University Hospitals, USA
| | - Giles J Peek
- Congenital Heart Center, Department of Surgery, University of Florida, USA
| | - on behalf of the Covid-19 Critical Care Consortium (COVID
Critical)
- Division of Cardiothoracic
Surgery, Department of Surgery, Emory School of
Medicine, USA
- Department of Critical Care
Medicine, MedStar Washington Hospital
Center, Georgetown University, USA
- Medical Intensive Care
Unit, Department of Medicine, Hamad General Hospital, Qatar
- School of Public Health & Social
Work, Queensland University of
Technology, Australia
- Department of Cardiovascular &
Thoracic Surgery, West Virginia
University, USA
- Department of Medicine, Section of Critical Care
Medicine, Max Rady College of
Medicine, University of Manitoba, Canada
- Department of Surgery, Section of Cardiac
Surgery, Max Rady College of
Medicine, University of Manitoba, Canada
- Congenital Heart Center, Department of Surgery, University of Florida, USA
- Critical Care Research
Group, The Prince Charles
Hospital, and University of
Queensland, Australia
- Heart &Vascular
Institute, Division of Cardiac
Surgery, University Hospitals, USA
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Shen M, Huai J. Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome With COVID-19: A Meta-Analysis. Cureus 2024; 16:e53049. [PMID: 38410333 PMCID: PMC10896011 DOI: 10.7759/cureus.53049] [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] [Accepted: 01/27/2024] [Indexed: 02/28/2024] Open
Abstract
The available literature has furnished substantial evidence indicating the favorable outcomes of prone positioning (PP) on oxygenation parameters among patients afflicted with coronavirus disease 2019 (COVID-19). However, there is a notable disparity in the reported influence of PP on the overall outcomes of COVID-19 patients undergoing venovenous extracorporeal membrane oxygenation (V-V ECMO) for acute respiratory distress syndrome (ARDS) across studies. This article has been prepared in adherence with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. MEDLINE, Embase, and Cochrane databases were utilized for data retrieval. The primary endpoint was to evaluate the cumulative survival rate among COVID-19 patients receiving V-V ECMO, comparing those who received PP to those who did not. Secondary endpoints included the duration of intensive care unit (ICU) stay, ECMO duration, and mechanical ventilation duration. A total of 15 studies involving 2286 patients were analyzed in the meta-analysis. PP significantly improved the cumulative survival rate (0.48, 95% CI: 0.40-0.55); risk ratio (RR) of 1.24 (95% CI: 1.11-1.38).PP during ECMO for COVID-19 patients yielded favorable outcomes in terms of 60-day survival, 90-day survival, ICU survival, and hospital survival. In contrast, patients who underwent PP had longer ECMO duration (8.1 days, 95% CI: 6.2-9.9, p<0.001) and mechanical ventilation duration (9.6 days, 95% CI: 8.0-11.2, p<0.001). PP demonstrated improved survival in COVID-19 patients with ARDS receiving V-V ECMO. However, additional well-designed prospective trials are warranted to further explore the effects of this combination on survival outcomes in COVID-19 patients.
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Affiliation(s)
- Minjin Shen
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, CHN
| | - Jiaping Huai
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, CHN
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Schmidt M, Hajage D, Lebreton G, Dres M, Guervilly C, Richard JC, Sonneville R, Winiszewski H, Muller G, Beduneau G, Mercier E, Roze H, Lesouhaitier M, Terzi N, Thille AW, Laurent I, Kimmoun A, Combes A. Prone Positioning During Extracorporeal Membrane Oxygenation in Patients With Severe ARDS: The PRONECMO Randomized Clinical Trial. JAMA 2023; 330:2343-2353. [PMID: 38038395 PMCID: PMC10692949 DOI: 10.1001/jama.2023.24491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023]
Abstract
Importance Prone positioning may improve outcomes in patients with severe acute respiratory distress syndrome (ARDS), but it is unknown whether prone positioning improves clinical outcomes among patients with ARDS who are undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO) compared with supine positioning. Objective To test whether prone positioning vs supine positioning decreases the time to successful ECMO weaning in patients with severe ARDS supported by VV-ECMO. Design, Setting, and Participants Randomized clinical trial of patients with severe ARDS undergoing VV-ECMO for less than 48 hours at 14 intensive care units (ICUs) in France between March 3, 2021, and December 7, 2021. Interventions Patients were randomized 1:1 to prone positioning (at least 4 sessions of 16 hours) (n = 86) or to supine positioning (n = 84). Main Outcomes and Measures The primary outcome was time to successful ECMO weaning within 60 days following randomization. Secondary outcomes included ECMO and mechanical ventilation-free days, ICU and hospital length of stay, skin pressure injury, serious adverse events, and all-cause mortality at 90-day follow-up. Results Among 170 randomized patients (median age, 51 [IQR, 43-59] years; n = 60 women [35%]), median respiratory system compliance was 15.0 (IQR, 10.7-20.6) mL/cm H2O; 159 patients (94%) had COVID-19-related ARDS; and 164 (96%) were in prone position before ECMO initiation. Within 60 days of enrollment, 38 of 86 patients (44%) had successful ECMO weaning in the prone ECMO group compared with 37 of 84 (44%) in the supine ECMO group (risk difference, 0.1% [95% CI, -14.9% to 15.2%]; subdistribution hazard ratio, 1.11 [95% CI, 0.71-1.75]; P = .64). Within 90 days, no significant difference was observed in ECMO duration (28 vs 32 days; difference, -4.9 [95% CI, -11.2 to 1.5] days; P = .13), ICU length of stay, or 90-day mortality (51% vs 48%; risk difference, 2.4% [95% CI, -13.9% to 18.6%]; P = .62). No serious adverse events were reported during the prone position procedure. Conclusions and Relevance Among patients with severe ARDS supported by VV-ECMO, prone positioning compared with supine positioning did not significantly reduce time to successful weaning of ECMO. Trial Registration ClinicalTrials.gov Identifier: NCT04607551.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique–Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France
- GRC 30 RESPIRE, Sorbonne Université, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Assistance Publique–Hôpitaux de Paris, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), CIC-1421, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique–Hôpitaux de Paris, Thoracic and Cardiovascular Department, Hôpital Pitié-Salpêtrière, Paris France
| | - Martin Dres
- GRC 30 RESPIRE, Sorbonne Université, Paris, France
- Assistance Publique–Hôpitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), et Sorbonne Université, INSERM, UMRS-1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Christophe Guervilly
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Centre d’Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Marseille, France
| | - Jean Christophe Richard
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| | - Romain Sonneville
- Université Paris Cité, INSERM U1137, F-75018 Paris, APHP Nord, Service de Médecine Intensive Réanimation, Hôpital Bichat–Claude Bernard, Paris, France
| | | | - Gregoire Muller
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d’Orléans, Orléans, France
| | - Gaëtan Beduneau
- Université Rouen Normandie, Normandie Université, GRHVN UR 3830, Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Emmanuelle Mercier
- Service de Médecine Intensive Réanimation, CHU de Tours, CRICS-TRIGGERSEP Network, Tours, France
| | - Hadrien Roze
- Service d’Anesthésie Réanimation Thoraco-Abdominale, CMC Magellan, Hôpital, Haut Leveque, CHU de Bordeaux, INSERM 1045: Centre de Recherche Cardio-Thoracique, Université de Bordeaux, Pessac, France
| | - Mathieu Lesouhaitier
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Nicolas Terzi
- Service de Médecine Intensive Réanimation, Université de Grenoble-Alpes, Inserm U1042, Grenoble, France
| | - Arnaud W. Thille
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France
| | - Isaura Laurent
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Assistance Publique–Hôpitaux de Paris, Hôpitaux Universitaires Pitié Salpêtrière–Charles Foix, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), CIC-1421, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Service de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT, Nancy, France
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique–Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France
- GRC 30 RESPIRE, Sorbonne Université, Paris, France
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Teijeiro-Paradis R, Ferguson ND. Prone Positioning During Venovenous ECMO for Severe ARDS. JAMA 2023; 330:2341-2342. [PMID: 38038393 DOI: 10.1001/jama.2023.22456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, and Institute of Health Policy, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Respirology and Critical Care, Sinai Health System and University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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Artaud-Macari E, Le Bouar G, Maris J, Dantoing E, Vatignez T, Girault C. [Ventilatory management of SARS-CoV-2 acute respiratory failure]. Rev Mal Respir 2023; 40:751-767. [PMID: 37865564 DOI: 10.1016/j.rmr.2023.09.005] [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: 04/16/2023] [Accepted: 09/19/2023] [Indexed: 10/23/2023]
Abstract
COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.
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Affiliation(s)
- E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France; UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France.
| | - G Le Bouar
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - J Maris
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - E Dantoing
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - T Vatignez
- Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| | - C Girault
- UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France; Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
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Adelsten J, Grønlykke L, Pedersen FM, Madsen SA, Sørensen M, Eschen CT, Møller Sørensen PH, Gjedsted J, Nielsen DV, Christensen S, Nielsen J, Jørgensen VL. Use of prone position ventilation in patients with COVID-19 induced severe ARDS supported with V-V ECMO: A danish cohort study with focus on adverse events. Perfusion 2023:2676591231198798. [PMID: 37787741 DOI: 10.1177/02676591231198798] [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: 10/04/2023]
Abstract
INTRODUCTION Prone position ventilation (PPV) of patients with adult respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) may improve oxygenation and alveolar recruitment and is recommended when extensive dorsal consolidations are present, but only few data regarding adverse events (AE) related to PPV in this group of patients have been published. METHODS Nationwide retrospective analysis of 68 COVID-19 patients admitted from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. The number of patients treated with PPV, number of PPV-events, timing, the time spent in prone position, number and causes of AE are reported. Causes to stop the PPV regimen and risk factors for AE were explored. RESULTS 44 out of 68 patients were treated with PPV, and 220 PPV events are evaluated. AE were identified in 99 out of 220 (45%) PPV events and occurred among 31 patients (71%). 1 fatal PPV related AE was registered. Acute supination occurred in 19 events (9%). Causes to stop the PPV regimen were almost equally distributed between effect (weaned from ECMO), no effect, death (of other reasons) and AE. Frequent causes of AE were pressures sores and ulcers, hypoxia, airway related and ECMO circuit related. Most AE occurred during patients first or second PPV event. CONCLUSIONS PPV treatment was found to carry a high incidence of PPV related AE in these patients. Causes and preventive measures to reduce occurrence of PPV related AE during V-V ECMO support need further exploration.
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Affiliation(s)
- Janne Adelsten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Møller Pedersen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Camilla Tofte Eschen
- Department of Anaesthesiology and Intensive Care, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Peter Hasse Møller Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorthe Viemose Nielsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Nielsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Kneyber MCJ, Cheifetz IM. Mechanical ventilation during pediatric extracorporeal life support. Curr Opin Pediatr 2023; 35:596-602. [PMID: 37497765 DOI: 10.1097/mop.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW To discuss the role of ventilator induced lung injury (VILI) and patient self-inflicted lung injury in ventilated children supported on extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS While extracorporeal life support is used routinely used every day around the globe to support neonatal, pediatric, and adult patients with refractory cardiac and/or respiratory failure, the optimal approach to mechanical ventilation, especially for those with acute respiratory distress syndrome (ARDS), remains unknown and controversial. Given the lack of definitive data in this population, one must rely on available evidence in those with ARDS not supported with ECMO and extrapolate adult observations. Ventilatory management should include, as a minimum standard, limiting inspiratory and driving pressures, providing a sufficient level of positive end-expiratory pressure, and setting a low rate to reduce mechanical power. Allowing for spontaneous breathing and use of pulmonary specific ancillary treatment modalities must be individualized, while balancing the risk and benefits. Future studies delineating the best strategies for optimizing MV during pediatric extracorporeal life support are much needed. SUMMARY Future investigations will hopefully provide the needed evidence and better understanding of the overall goal of reducing mechanical ventilation intensity to decrease risk for VILI and promote lung recovery for those supported with ECMO.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen
- Critical care, Anesthesiology, Peri-operative & Emergency medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Li J, Ibarra-Estrada M, Guérin C. Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script. Respir Care 2023; 68:1449-1464. [PMID: 37722733 PMCID: PMC10506644 DOI: 10.4187/respcare.11227] [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] [Indexed: 09/20/2023]
Abstract
During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois.
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde Guadalajara, Universidad de Guadalajara, Jalisco, México; Grupo Internacional de Ventilación Mecánica WeVent; and Latin American Intensive Care Network (LIVEN)
| | - Claude Guérin
- Médecine Intensive Réanimation, Hôpital Édouard Herriot, Lyon, France; Université de Lyon, Lyon, France; and Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7000, Créteil, France
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Paparoupa M, Fischer M, Pinnschmidt HO, Grensemann J, Roedl K, Kluge S, Jarczak D. Impact of COVID-19 on Sedation Requirements during Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. J Clin Med 2023; 12:jcm12103515. [PMID: 37240620 DOI: 10.3390/jcm12103515] [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: 04/19/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
COVID-19-associated ARDS (C-ARDS) is mentioned to express higher analgosedation needs, in comparison to ARDS of other etiologies. The objective of this monocentric retrospective cohort study was to compare the analgosedation needs between C-ARDS and non-COVID-19 ARDS (non-C-ARDS) on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Data were collected from the electronic medical records of all adult patients treated with C-ARDS in our Department of Intensive Care Medicine between March 2020 and April 2022. The control group included patients treated with non-C-ARDS between the years 2009 and 2020. A sedation sum score was created in order to describe the overall analgosedation needs. A total of 115 (31.5%) patients with C-ARDS and 250 (68.5%) with non-C-ARDS requiring VV-ECMO therapy were included in the study. The sedation sum score was significantly higher in the C-ARDS group (p < 0.001). COVID-19 was significantly associated with analgosedation in the univariable analysis. By contrast, the multivariable model did not show a significant association between COVID-19 and the sum score. The year of VV-ECMO support, BMI, SAPS II and prone positioning were significantly associated with sedation needs. The potential impact of COVID-19 remains unclear, and further studies are warranted in order to evaluate specific disease characteristics linked with analgesia and sedation.
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Affiliation(s)
- Maria Paparoupa
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Rabie AA, Elhazmi A, Azzam MH, Abdelbary A, Labib A, Combes A, Zakhary B, MacLaren G, Barbaro RP, Peek GJ, Antonini MV, Shekar K, Al-Fares A, Oza P, Mehta Y, Alfoudri H, Ramanathan K, Ogino M, Raman L, Paden M, Brodie D, Bartlett R. Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study. Ann Intensive Care 2023; 13:36. [PMID: 37129771 PMCID: PMC10152433 DOI: 10.1186/s13613-023-01126-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/05/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus. OBJECTIVES To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS. METHODS The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel's questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively. RESULTS In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics. CONCLUSION Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations.
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Affiliation(s)
- Ahmed A Rabie
- Critical Care Department-ECMO care Unit (ECU), Riyadh Region Cluster1, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Alyaa Elhazmi
- Internal Medicine Department, King Faisal University, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Adult Critical Care Department, Dr. Sulaiman Alhabib Medical Group, Jeddah, Saudi Arabia
| | | | - Ahmed Labib
- Hamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, 75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | | | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, Singapore, Singapore
| | - Ryan P Barbaro
- Division of Pediatric Critical Care and Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | | | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Ministry of Health, Kuwait City, Kuwait
- Al-Amiri Hospital Center for Respiratory and Cardiac Failure, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
| | - Pranay Oza
- Riddhi Vinayak Multispecialty Hospital, Mumbai, India
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, 122001, Haryana, India
| | - Huda Alfoudri
- Department of Anaesthesia, Critical Care, and Pain Management, Al-Adan Hospital Ministry of Health, Hadiya, Kuwait
| | | | - Mark Ogino
- Chief Partnership Officer, Nemours Children's Health, Delaware Valley, USA
| | - Lakshmi Raman
- Division of Paediatric Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Paden
- Division of Paediatric Critical Care, Emory University, Atlanta, GA, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian/Columbia University Medical Center, New York, USA
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11
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Lorusso R, De Piero ME, Mariani S, Di Mauro M. Determinants of long-term outcomes in patients with COVID-19 supported with ECMO - Authors' reply. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e42. [PMID: 37030307 PMCID: PMC10075998 DOI: 10.1016/s2213-2600(23)00134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 04/10/2023]
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
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12
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Assouline B, Combes A, Schmidt M. Setting and Monitoring of Mechanical Ventilation During Venovenous ECMO. Crit Care 2023; 27:95. [PMID: 36941722 PMCID: PMC10027594 DOI: 10.1186/s13054-023-04372-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Combes
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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13
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Prolonged Noninvasive Respiratory Support Before Intubation Is Associated With Increased Duration of Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:e118-e120. [PMID: 36227730 DOI: 10.1097/mat.0000000000001810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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14
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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15
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Abstract
OBJECTIVES Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the two therapies is feasible and safe, but the effectiveness is not known. Our objective was to evaluate the potential survival benefit of prone positioning in venovenous ECMO patients cannulated for COVID-19-related ARDS. DESIGN Retrospective analysis of a multicenter cohort. PATIENTS Patients on venovenous ECMO who tested positive for severe acute respiratory syndrome coronavirus 2 by reverse transcriptase polymerase chain reaction or with a diagnosis on chest CT were eligible. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients on venovenous ECMO for respiratory failure in whom prone position status while on ECMO and in-hospital mortality were known were included. Of 647 patients in 41 centers, 517 were included. Median age was 55 (47-61), 78% were male and 95% were proned before cannulation. After cannulation, 364 patients (70%) were proned and 153 (30%) remained in the supine position for the whole ECMO run. There were 194 (53%) and 92 (60%) deaths in the prone and the supine groups, respectively. Prone position on ECMO was independently associated with lower in-hospital mortality (odds ratio = 0.49 [0.29-0.84]; p = 0.010). In 153 propensity score-matched pairs, mortality rate was 49.7% in the prone position group versus 60.1% in the supine position group (p = 0.085). Considering only patients alive at decannulation, propensity-matched proned patients had a significantly lower mortality rate (22.4% vs 37.8%; p = 0.029) than nonproned patients. CONCLUSIONS Prone position may be beneficial in patients supported by venovenous ECMO for COVID-19-related ARDS but more data are needed to draw definitive conclusions.
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16
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Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome-Better Together? Crit Care Med 2023; 51:143-145. [PMID: 36519989 DOI: 10.1097/ccm.0000000000005727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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17
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Giani M, Rezoagli E, Guervilly C, Rilinger J, Duburcq T, Petit M, Textoris L, Garcia B, Wengenmayer T, Bellani G, Grasselli G, Pesenti A, Combes A, Foti G, Schmidt M. Timing of Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. Crit Care Med 2023; 51:25-35. [PMID: 36519981 DOI: 10.1097/ccm.0000000000005705] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the association of timing to prone positioning (PP) during venovenous extracorporeal membrane oxygenation (V-V ECMO) with the probability of being discharged alive from the ICU at 90 days (primary endpoint) and the improvement of the respiratory system compliance (Cpl,rs). DESIGN Pooled individual data analysis from five original observational cohort studies. SETTING European extracorporeal membrane oxygenation (ECMO) centers. PATIENTS Acute respiratory distress syndrome (ARDS) patients who underwent PP during ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Time to PP during V-V ECMO was explored both as a continuous and a categorical variable with Cox proportional hazard models. Three hundred patients were included in the analysis. The longer the time to PP during V-V ECMO, the lower the adjusted probability of alive ICU discharge (adjusted hazard ratio [HR] 0.90 for each day increase; 95% CI, 0.87-0.93). Two hundred twenty-three and 77 patients were included in the early PP (≤ 5 d) and late PP (> 5 d) groups, respectively. The cumulative 90-day probability of being discharged alive from the ICU was 61% in the early PP group vs 36% in the late PP group (log-rank test, p <0.001). This benefit was maintained after adjustment for confounders (adjusted HR, 2.52; 95% CI, 1.66-3.81; p <0.001). In the early PP group, PP was associated with a significant improvement of Cpl,rs (4 ± 9 mL/cm H2O vs 0 ± 12 in the late PP group, p=0.038). CONCLUSIONS In a large cohort of ARDS patients on ECMO, early PP during ECMO was associated with a higher probability of being discharged alive from the ICU at 90 days and a greater improvement of Cpl,rs.
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Affiliation(s)
- Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Christophe Guervilly
- Medical Intensive Care Unit North Hospital, Department of Anaesthesiology and Critical Care, APHM, Marseille, France
- CER- eSS, Center for Studies and Research On Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Thibault Duburcq
- Service de Médecine Intensive-Réanimation, Department of Anaesthesiology and Critical Care, CHU Lille, F-59000 Lille, France
| | - Matthieu Petit
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié- Salpêtrière, Paris, France
| | - Laura Textoris
- Medical Intensive Care Unit North Hospital, Department of Anaesthesiology and Critical Care, APHM, Marseille, France
| | - Bruno Garcia
- Service de Médecine Intensive-Réanimation, Department of Anaesthesiology and Critical Care, CHU Lille, F-59000 Lille, France
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié- Salpêtrière, Paris, France
- INSERM, UMRS 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, ASST Monza, Monza, Italy
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne Université Hôpital Pitié- Salpêtrière, Paris, France
- INSERM, UMRS 1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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18
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Abstract
OBJECTIVES Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the two therapies is feasible and safe, but the effectiveness is not known. Our objective was to evaluate the potential survival benefit of prone positioning in venovenous ECMO patients cannulated for COVID-19-related ARDS. DESIGN Retrospective analysis of a multicenter cohort. PATIENTS Patients on venovenous ECMO who tested positive for severe acute respiratory syndrome coronavirus 2 by reverse transcriptase polymerase chain reaction or with a diagnosis on chest CT were eligible. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients on venovenous ECMO for respiratory failure in whom prone position status while on ECMO and in-hospital mortality were known were included. Of 647 patients in 41 centers, 517 were included. Median age was 55 (47-61), 78% were male and 95% were proned before cannulation. After cannulation, 364 patients (70%) were proned and 153 (30%) remained in the supine position for the whole ECMO run. There were 194 (53%) and 92 (60%) deaths in the prone and the supine groups, respectively. Prone position on ECMO was independently associated with lower in-hospital mortality (odds ratio = 0.49 [0.29-0.84]; p = 0.010). In 153 propensity score-matched pairs, mortality rate was 49.7% in the prone position group versus 60.1% in the supine position group (p = 0.085). Considering only patients alive at decannulation, propensity-matched proned patients had a significantly lower mortality rate (22.4% vs 37.8%; p = 0.029) than nonproned patients. CONCLUSIONS Prone position may be beneficial in patients supported by venovenous ECMO for COVID-19-related ARDS but more data are needed to draw definitive conclusions.
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19
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[Not Available]. REVUE DES MALADIES RESPIRATOIRES ACTUALITES 2022; 14:2S483-2S491. [PMID: 36536952 PMCID: PMC9752049 DOI: 10.1016/s1877-1203(22)00785-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Zhang H, Liu Z, Shu H, Yu Y, Yang X, Li R, Xu J, Zou X, Shang Y. Prone positioning in ARDS patients supported with VV ECMO, what we should explore? J Intensive Care 2022; 10:46. [PMID: 36195935 PMCID: PMC9531855 DOI: 10.1186/s40560-022-00640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS), a prevalent cause of admittance to intensive care units, is associated with high mortality. Prone positioning has been proven to improve the outcomes of moderate to severe ARDS patients owing to its physiological effects. Venovenous extracorporeal membrane oxygenation (VV ECMO) will be considered in patients with severe hypoxemia. However, for patients with severe hypoxemia supported with VV ECMO, the potential effects and optimal strategies of prone positioning remain unclear. This review aimed to present these controversial questions and highlight directions for future research. Main body The clinically significant benefit of prone positioning and early VV ECMO alone was confirmed in patients with severe ARDS. However, a number of questions regarding the combination of VV ECMO and prone positioning remain unanswered. We discussed the potential effects of prone positioning on gas exchange, respiratory mechanics, hemodynamics, and outcomes. Strategies to achieve optimal outcomes, including indications, timing, duration, and frequency of prone positioning, as well as the management of respiratory drive during prone positioning sessions in ARDS patients receiving VV ECMO, are challenging and controversial. Additionally, whether and how to implement prone positioning according to ARDS phenotypes should be evaluated. Lung morphology monitored by computed tomography, lung ultrasound, or electrical impedance tomography might be a potential indication to make an individualized plan for prone positioning therapy in patients supported with VV ECMO. Conclusion For patients with ARDS supported with VV ECMO, the potential effects of prone positioning have yet to be clarified. Ensuring an optimal strategy, especially an individualized plan for prone positioning therapy during VV ECMO, is particularly challenging and requires further research.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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21
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Chen Z, Li M, Gu S, Huang X, Xia J, Ye Q, Zheng J, Zhan Q, Wang C. Effect of prone position in patients with acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation: a retrospective cohort study. BMC Pulm Med 2022; 22:234. [PMID: 35710365 PMCID: PMC9202669 DOI: 10.1186/s12890-022-02026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background The application of prone position (PP) in acute respiratory distress syndrome (ARDS) supported by venovenous extracorporeal membrane oxygenation (VV-ECMO) is controversial.
Objectives To evaluate the safety and efficacy of application of PP during VV-ECMO in patients with ARDS.
Methods This was a single-center, retrospective study of patients who met the Berlin definition of ARDS, and were supported with VV-ECMO. We divided the patients into two groups. The prone group included patients who were supported by VV-ECMO, and experienced at least one period of PP, while those without PP during VV-ECMO were defined as the supine group. Propensity score matching (PSM) at a ratio of 1:1 was introduced to minimize potential confounders. The primary outcomes were the complications of PP and the change of arterial oxygen pressure/fraction of the inspiration (PaO2/FiO2) ratio after PP. The secondary outcomes were hospital survival, ICU survival, and ECMO weaning rate. Results From April 2013 to October 2020, a total of 91 patients met the diagnostic criteria of ARDS who were supported with ECMO. 38 patients (41.8%) received at least one period of PP during ECMO, while 53 patients (58.2%) were maintained in supine position during ECMO. 22 minor complications were reported in the prone group and major complications were not found. The other ECMO-related complications were similar between two groups. The PaO2/FiO2 ratio significantly improved after PP compared with before (174.50 (132.40–228.25) mmHg vs. 158.00 (122.93–210.33) mmHg, p < 0.001). PSM selected 25 pairs of patients with similar characteristics. Hospital survival or ICU survival did not differ between the two groups (40% vs. 28%, p = 0.370; 40% vs. 32%, p = 0.556). Significant difference of ECMO weaning rate between two groups was not found (56% vs. 32%, p = 0.087). Conclusions PP during VV-ECMO was safe and could improve oxygenation. A large-scale and well-designed RCT is needed in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02026-7.
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Affiliation(s)
- Ziying Chen
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Min Li
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Sichao Gu
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Xu Huang
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Jingen Xia
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Qinghua Ye
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Jiangnan Zheng
- Department of Pulmonary and Critical Care Medicine, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, People's Republic of China
| | - Qingyuan Zhan
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China. .,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China. .,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China. .,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China.
| | - Chen Wang
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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22
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Fior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med 2022; 43:417-425. [PMID: 35760300 DOI: 10.1055/s-0042-1749450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.
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Affiliation(s)
- Gabriele Fior
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Zasha F Vazquez Colon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Florida, Shands Children's Hospital, Gainesville, Florida
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, Shands Children's Hospital, Gainesville, University of Florida, Gainesville, Florida
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital and The Wesley Hospital, Uniting Care Hospitals, Brisbane, QLD, Australia
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23
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Zaaqoq AM, Barnett AG, Heinsar S, Griffee MJ, MacLaren G, Jacobs JP, Suen JY, Bassi GL, Fraser JF, Dalton HJ, Peek GJ. Prone position during venovenous extracorporeal membrane oxygenation: survival analysis needed for a time-dependent intervention. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:39. [PMID: 35135606 PMCID: PMC8822641 DOI: 10.1186/s13054-022-03923-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, 110 Irving St NW, office 4B-65, Washington, DC, 20010, USA.
| | - Adrian G Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Matthew J Griffee
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, National University of Singapore, Singapore, Singapore
| | - Jeffrey P Jacobs
- Congenital Heart Center, Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Institut d'Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Heidi J Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Giles J Peek
- Congenital Heart Center, Shands Children's Hospital, University of Florida, Gainesville, FL, USA
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24
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Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19.
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