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Chiscano-Camón L, Ruiz-Sanmartin A, Bajaña I, Bastidas J, Lopez-Martinez R, Franco-Jarava C, Gonzalez JJ, Larrosa N, Riera J, Nuvials-Casals X, Ruiz-Rodríguez JC, Ferrer R. Current perspectives in the management of sepsis and septic shock. Front Med (Lausanne) 2024; 11:1431791. [PMID: 39211340 PMCID: PMC11358069 DOI: 10.3389/fmed.2024.1431791] [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: 05/12/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024] Open
Abstract
Within patients with sepsis, there exists significant heterogeneity, and while all patients should receive conventional therapy, there are subgroups of patients who may benefit from specific therapies, often referred to as rescue therapies. Therefore, the identification of these specific patient subgroups is crucial and lays the groundwork for the application of precision medicine based on the development of targeted interventions. Over the years, efforts have been made to categorize sepsis into different subtypes based on clinical characteristics, biomarkers, or underlying mechanisms. For example, sepsis can be stratified into different phenotypes based on the predominant dysregulated host response. These phenotypes can range from hyperinflammatory states to immunosuppressive states and even mixed phenotypes. Each phenotype may require different therapeutic approaches to improve patient outcomes. Rescue strategies for septic shock may encompass various interventions, such as immunomodulatory therapies, extracorporeal support (e.g., ECMO), or therapies targeted at specific molecular or cellular pathways involved in the pathophysiology of sepsis. In recent years, there has been growing interest in precision medicine approaches to sepsis and phenotype identification. Precision medicine aims to tailor treatments to each individual patient based on their unique characteristics and disease mechanisms.
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Affiliation(s)
- Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ivan Bajaña
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juliana Bastidas
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Rocio Lopez-Martinez
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Clara Franco-Jarava
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan José Gonzalez
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Xavier Nuvials-Casals
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
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Chen WY, Guo ZB, Kong TY, Chen WX, Chen XH, Yang Q, Wen YC, Wen QR, Zhou F, Xiong XM, Wen DL, Zhang ZH. ExtraCorporeal Membrane Oxygenation in the therapy for REfractory Septic shock with Cardiac function Under Estimated (ECMO-RESCUE): study protocol for a prospective, multicentre, non-randomised cohort study. BMJ Open 2024; 14:e079212. [PMID: 38858161 PMCID: PMC11168177 DOI: 10.1136/bmjopen-2023-079212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 05/10/2024] [Indexed: 06/12/2024] Open
Abstract
INTRODUCTION Severe septic cardiomyopathy (SCM) is one of the main causes of refractory septic shock (RSS), with a high mortality. The application of venoarterial extracorporeal membrane oxygenation (ECMO) to support the impaired cardiac function in patients with septic shock remains controversial. Moreover, no prospective studies have been taken to address whether venoarterial ECMO treatment could improve the outcome of patients with sepsis-induced cardiogenic shock. The objective of this study is to assess whether venoarterial ECMO treatment can improve the 30-day survival rate of patients with sepsis-induced refractory cardiogenic shock. METHODS AND ANALYSIS ExtraCorporeal Membrane Oxygenation in the therapy for REfractory Septic shock with Cardiac function Under Estimated is a prospective, multicentre, non-randomised, cohort study on the application of ECMO in SCM. At least 64 patients with SCM and RSS will be enrolled in an estimated ratio of 1:1.5. Participants taking venoarterial ECMO during the period of study are referred to as cohort 1, and patients receiving only conventional therapy without ECMO belong to cohort 2. The primary outcome is survival in a 30-day follow-up period. Other end points include survival to intensive care unit (ICU) discharge, hospital survival, 6-month survival, quality of life for long-term survival (EQ-5D score), successful rate of ECMO weaning, long-term survivors' cardiac function, the number of days alive without continuous renal replacement therapy, mechanical ventilation and vasopressor, ICU and hospital length of stay, the rate of complications potentially related to ECMO treatment. ETHICS AND DISSEMINATION The trial has been approved by the Clinical Research and Application Institutional Review Board of the Second Affiliated Hospital of Guangzhou Medical University (2020-hs-51). Participants will be screened and enrolled from ICU patients with septic shock by clinicians, with no public advertisement for recruitment. Results will be disseminated in research journals and through conference presentations. TRIAL REGISTRATION NUMBER NCT05184296.
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Affiliation(s)
- Wei-Yan Chen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Ze-Bin Guo
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Tian-Yu Kong
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Wei-Xiao Chen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Xiao-Hua Chen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Qilin Yang
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Yi-Chao Wen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Qi-Rui Wen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Feng Zhou
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Xu-Ming Xiong
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - De-Liang Wen
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
| | - Zhen-Hui Zhang
- Intensive Care Unit, Guangzhou Medical University Second Affiliated Hospital, Guangzhou, Guangdong, China
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Ruiz-Rodríguez JC, Chiscano-Camón L, Maldonado C, Ruiz-Sanmartin A, Martin L, Bajaña I, Bastidas J, Lopez-Martinez R, Franco-Jarava C, González-López JJ, Ribas V, Larrosa N, Riera J, Nuvials-Casals X, Ferrer R. Catastrophic Streptococcus pyogenes Disease: A Personalized Approach Based on Phenotypes and Treatable Traits. Antibiotics (Basel) 2024; 13:187. [PMID: 38391573 PMCID: PMC10886101 DOI: 10.3390/antibiotics13020187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Streptococcal toxic shock syndrome (STTS) is a critical medical emergency marked by high morbidity and mortality, necessitating swift awareness, targeted treatment, and early source control due to its rapid symptom manifestation. This report focuses on a cohort of 13 patients admitted to Vall d'Hebron University Hospital Intensive Care Unit, Barcelona, from November 2022 to March 2023, exhibiting invasive Streptococcus pyogenes infections and meeting institutional sepsis code activation criteria. The primary infections were community-acquired pneumonia (61.5%) and skin/soft tissue infection (30.8%). All patients received prompt antibiotic treatment, with clinical source control through thoracic drainage (30.8%) or surgical means (23.1%). Organ support involved invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy as per guidelines. Of note, 76.9% of patients experienced septic cardiomyopathy, and 53.8% required extracorporeal membrane oxygenation (ECMO). The study identified three distinct phenotypic profiles-hyperinflammatory, low perfusion, and hypogammaglobulinemic-which could guide personalized therapeutic approaches. STTS, with a mean SOFA score of 17 (5.7) and a 53.8% requiring ECMO, underscores the need for precision medicine-based rescue therapies and sepsis phenotype identification. Integrating these strategies with prompt antibiotics and efficient source control offers a potential avenue to mitigate organ failure, enhancing patient survival and recovery in the face of this severe clinical condition.
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Affiliation(s)
- Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Departament of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
| | - Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Departament of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
| | - Carolina Maldonado
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Laura Martin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Ivan Bajaña
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Juliana Bastidas
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Rocio Lopez-Martinez
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Clara Franco-Jarava
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Juan José González-López
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Vicent Ribas
- Eurecat, Centre Tecnològic de Catalunya, EHealth Unit, 08005 Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Xavier Nuvials-Casals
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Departament of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
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Kayumov M, Habimana R, Kim D, Obiweluozor FO, Jeong IS, Cho HJ. Extracorporeal circulation models in small animals: beyond the limits of preclinical research. Acute Crit Care 2023; 38:1-7. [PMID: 36935529 PMCID: PMC10030238 DOI: 10.4266/acc.2023.00381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) use has remarkably increased in recent years. Although ECMO has become essential for patients with refractory cardiac and respiratory failure, extracorporeal circulation (ECC) is associated with significant complications. Small-animal models of ECC have been developed and widely used to better understand ECC-induced pathophysiology. This review article summarizes the development of small-animal ECC models, including the animal species, circuit configuration, priming, perioperative procedures, cannulation, and future perspectives of small-animal ECMO models.
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Affiliation(s)
- Mukhammad Kayumov
- Department of Medical Science, Chonnam National University Graduate School, Gwangju, Korea
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Hospital Medical School, Gwangju, Korea
- Extracorporeal Circulation Research Team, Chonnam National University Hospital, Gwangju, Korea
| | - Reverien Habimana
- Extracorporeal Circulation Research Team, Chonnam National University Hospital, Gwangju, Korea
- Department of Biomedical Sciences, Chonnam National University Graduate School, Chonnam National University Medical School, Gwangju, Korea
| | - Dowan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Hospital Medical School, Gwangju, Korea
- Extracorporeal Circulation Research Team, Chonnam National University Hospital, Gwangju, Korea
| | - Francis O Obiweluozor
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Hospital Medical School, Gwangju, Korea
- Extracorporeal Circulation Research Team, Chonnam National University Hospital, Gwangju, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Hospital Medical School, Gwangju, Korea
- Extracorporeal Circulation Research Team, Chonnam National University Hospital, Gwangju, Korea
| | - Hwa Jin Cho
- Extracorporeal Circulation Research Team, Chonnam National University Hospital, Gwangju, Korea
- Department of Pediatrics, Chonnam National University Children's Hospital and Chonnam National University Medical School, Gwangju, Korea
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Yousif A, Ali K, Anssar M, Harringer W, El-Essawi A, Brouwer R. A 20-year experience with cryopreserved allografts as the valve replacement of choice in aortic root reconstruction for destructive endocarditis with abscess formation. Interact Cardiovasc Thorac Surg 2022; 35:6628590. [PMID: 35786719 PMCID: PMC9270860 DOI: 10.1093/icvts/ivac188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/23/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Afram Yousif
- Department of Cardiothoracic and Vascular Surgery, Braunschweig Clinic , Braunschweig, Germany
| | - Khaldoun Ali
- Department of Cardiothoracic and Vascular Surgery, Braunschweig Clinic , Braunschweig, Germany
| | - Marcel Anssar
- Department of Cardiothoracic and Vascular Surgery, Braunschweig Clinic , Braunschweig, Germany
| | - Wolfgang Harringer
- Department of Cardiothoracic and Vascular Surgery, Braunschweig Clinic , Braunschweig, Germany
| | - Aschraf El-Essawi
- Department of Cardiothoracic and Vascular Surgery, University of Göttingen , Göttingen, Germany
| | - René Brouwer
- Department of Cardiothoracic and Vascular Surgery, Braunschweig Clinic , Braunschweig, Germany
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Del Río-Carbajo L, Nieto-Del Olmo J, Fernández-Ugidos P, Vidal-Cortés P. [Resuscitation strategy for patients with sepsis and septic shock]. Med Intensiva 2022; 46 Suppl 1:60-71. [PMID: 38341261 DOI: 10.1016/j.medine.2022.02.025] [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: 01/07/2022] [Accepted: 02/11/2022] [Indexed: 02/12/2024]
Abstract
Fluid and vasopressor resuscitation is, along with antimicrobial therapy and control of the focus of infection, a basic issue of the treatment of sepsis and septic shock. There is currently no accepted protocol that we can follow for the resuscitation of these patients and the Surviving Sepsis Campaign proposes controversial measures and without sufficient evidence support to establish firm recommendations. We propose a resuscitation strategy adapted to the situation of each patient: in the patient in whom community sepsis is suspected, we consider that the early administration of 30mL/kg of crystalloids is effective and safe; in the patient with nosocomial sepsis, we must carry out a more in-depth evaluation before initiating aggressive resuscitation. In patients who do not respond to initial resuscitation, it is necessary to increase monitoring level and, depending on the hemodynamic profile, administer more fluids, a second vasopressor or inotropes.
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Affiliation(s)
- L Del Río-Carbajo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - J Nieto-Del Olmo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - P Fernández-Ugidos
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - P Vidal-Cortés
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España.
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Estrategia integral de reanimación del paciente con sepsis y shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
PURPOSE OF REVIEW The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients. RECENT FINDINGS The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center. SUMMARY Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.
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Brogan TV, Thiagarajan RR, Lorusso R, McMullan DM, Di Nardo M, Ogino MT, Dalton HJ, Burke CR, Capatos G. The use of extracorporeal membrane oxygenation in human immunodeficiency virus-positive patients: a review of a multicenter database. Perfusion 2020; 35:772-777. [PMID: 32141382 DOI: 10.1177/0267659120906966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM We chose to evaluate the survival of extracorporeal membrane oxygenation among patients with human immunodeficiency virus in a multicenter registry. METHODS Retrospective case review of the Extracorporeal Life Support Organization Registry respiratory failure of all patients with human immunodeficiency virus supported with extracorporeal membrane oxygenation. RESULTS A total of 126 patients were included. Survival to discharge was 36%. Eight infants were supported with extracorporeal membrane oxygenation and three (37.5%) survived to discharge. Respiratory extracorporeal membrane oxygenation was the primary indication (78%) with a 39% survival, while cardiac and extracorporeal cardiopulmonary resuscitation indications accounted for 16% and 6% of patients with survivals of 30% and 12.5%, respectively. These differences did not reach significance. There were no significant differences between survivors and non-survivors in demographic data, but non-survivors had significantly more non-human immunodeficiency virus pre-extracorporeal membrane oxygenation infections than survivors. There were no differences in other pre-extracorporeal membrane oxygenation supportive therapies, mechanical ventilator settings, or arterial blood gas results between survivors and non-survivors. The median duration of mechanical ventilation prior to cannulation was 52 (interquartile range: 13-140) hours, while the median duration of the extracorporeal membrane oxygenation exposure was 237 (interquartile range: 125-622) hours. Ventilator settings were significantly lower after 24 hours compared to pre-extracorporeal membrane oxygenation settings. Complications during extracorporeal membrane oxygenation exposure including receipt of renal replacement therapy, inotropic infusions, and cardiopulmonary resuscitation were more common among non-survivors compared to survivors. Central nervous system complications were rare. CONCLUSION Survival among patients with human immunodeficiency virus infection who receive extracorporeal membrane oxygenation was less than 40%. Infections before extracorporeal membrane oxygenation cannulation occurred more often in non-survivors. The receipt of renal replacement therapy, inotropic infusions, or cardiopulmonary resuscitation during extracorporeal membrane oxygenation was associated with worse outcome.
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Affiliation(s)
- Thomas V Brogan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Ravi R Thiagarajan
- Department of Cardiology, Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - D Michael McMullan
- Division of Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Mark T Ogino
- Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College, Thomas Jefferson University, Wilmington, DE, USA
| | | | - Christopher R Burke
- Department of Thoracic Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Gerry Capatos
- Mediclinic Parkview Hospital, Dubai, United Arab Emirates
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Moula AI, Micali LR, Matteucci F, Lucà F, Rao CM, Parise O, Parise G, Gulizia MM, Gelsomino S. Quantification of Death Risk in Relation to Sex, Pre-Existing Cardiovascular Diseases and Risk Factors in COVID-19 Patients: Let's Take Stock and See Where We Are. J Clin Med 2020; 9:E2685. [PMID: 32825068 PMCID: PMC7564581 DOI: 10.3390/jcm9092685] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 01/08/2023] Open
Abstract
Patients with pre-existing cardiovascular disease (CVD) might be more susceptible to infection from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and have higher mortality rates. Nevertheless, the risk of mortality has not been previously quantified. The aim of this meta-analysis is to quantify the risk of mortality in coronavirus disease 2019 (COVID-19) patients. A meta-analysis was conducted analyzing the impact of (1) sex, (2) age, (3) CVD with coronary artery disease (CAD), (4) CAD alone, (5) CVD without CAD, (6) hypertension, (7) cerebrovascular diseases, and (8) diabetes on mortality. Relative risk was assessed for dichotomous variables, mean difference for continuous variables. Twenty-six studies were included, encompassing 8497 patients. Males had 16% higher risk of mortality than females (p < 0.05) and elderly patients had higher chance of dying than younger patients (p < 0.0001). Patients with overall CVD have a 1.96-fold higher mortality risk (p < 0.0001). CAD increases risk of mortality by 1.90-fold (p < 0.05). CVD-CAD were found to increase risk up to 2.03-fold (p < 0.05). Hypertension, cerebrovascular disease and diabetes increase the risk of death up to 1.73-fold, 1.76-fold and 1.59-fold, respectively (p < 0.0001, p < 0.0001, p < 0.05, respectively). Sex, age, presence of CAD and/or other types of CVD, hypertension, cerebrovascular diseases and diabetes mellitus increase mortality in patients with COVID-19.
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Affiliation(s)
- Amalia Ioanna Moula
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (A.I.M.); (L.R.M.); (F.M.); (O.P.); (G.P.)
| | - Linda Renata Micali
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (A.I.M.); (L.R.M.); (F.M.); (O.P.); (G.P.)
| | - Francesco Matteucci
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (A.I.M.); (L.R.M.); (F.M.); (O.P.); (G.P.)
| | - Fabiana Lucà
- Grande Ospedale Metropolitano, 89124 Reggio Calabria, Italy; (F.L.); (C.M.R.)
| | | | - Orlando Parise
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (A.I.M.); (L.R.M.); (F.M.); (O.P.); (G.P.)
| | - Gianmarco Parise
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (A.I.M.); (L.R.M.); (F.M.); (O.P.); (G.P.)
| | - Michele Massimo Gulizia
- Cardiogy Complex Unit, Garibaldi Nesima Hospital, 95122 Catania, Italy;
- Heart Care Foundation Onlus, 50121 Florence, Italy
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands; (A.I.M.); (L.R.M.); (F.M.); (O.P.); (G.P.)
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11
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Chen T, Zhu C, Liu B. Extracorporeal membrane oxygenation with continuous renal replacement therapy to treat metformin-associated lactic acidosis: A case report. Medicine (Baltimore) 2020; 99:e20990. [PMID: 32590812 PMCID: PMC7328913 DOI: 10.1097/md.0000000000020990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Metformin-associated lactic acidosis (MALA) is rarely encountered, but has a high mortality rate, Conventional treatments include hemodialysis or continuous renal replacement therapy (CRRT); however, when the disease progresses to end-stage, cardiac function is significantly inhibited, circulation cannot be maintained, CRRT cannot be tolerated, V-A extracorporeal membrane oxygenation (ECMO) may be the last treatment. PATIENT CONCERNS The study report a rare case of MALA in an elderly female patient at the age of 72 who was admitted to hospital because of nausea for 2 days, complicated with systemic fatigue. DIAGNOSIS MALA was cofirmed because of patient have increased lactic acid levels, blood pH <7.2, and a history of oral metformin intake. INTERVENTIONS Venoarterial ECMO (V-A ECMO) combined with CRRT was initiated when circulation was still not hold after intravenous fluids and 5% sodium bicarbonate were prescribed. OUTCOMES V-A ECMO was then terminated after 48 hours when circulation was perserved, CRRT was discontinued when PH and lactic acid level were normal limited. etformin-associated lactic acidosis did not recur during 6 months follow-up. LESSONS The incidence of MALA is low, but mortality is very high. Intermittent hemodialysis or CRRT should be performed if the lactic acid level is persistently elevated. When severe circulatory dysfunction occurs and cardiac function is inhibited, V-A ECMO support should be performed immediately to maintain circulation, followed by CRRT, which may be the final measure to treat refractory MALA.
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Affiliation(s)
- Ting Chen
- Department of Critical Care Medicine, The Second People's Hospital of Hefei, Yaohai District
| | - Chunyan Zhu
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Bao Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui, China
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12
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Buia A, Hopf HB, Herrmann E, Schmandra T, Hanisch E. Septic shock: ECMO beyond ARDS? Introducing the Simon two-stage protocol when randomisation is considered unethical. Scand J Trauma Resusc Emerg Med 2020; 28:22. [PMID: 32183853 PMCID: PMC7077119 DOI: 10.1186/s13049-020-0714-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 03/02/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Alexander Buia
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Röntgenstr 20, 63225, Langen, Germany.
| | - Hans-Bernd Hopf
- Department of Anaesthesia and Perioperative Medicine, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Röntgenstr 20, 63225, Langen, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Thomas Schmandra
- Department of Vascular Surgery, Rhön Klinik Campus Bad Neustadt, Von-Guttenberg-Str. 11, 97616, Bad Neustadt a. d. Saale, Germany
| | - Ernst Hanisch
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Röntgenstr 20, 63225, Langen, Germany
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13
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Han L, Zhang Y, Zhang Y, Wu W, He P. Risk factors for refractory septic shock treated with VA ECMO. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:476. [PMID: 31700912 DOI: 10.21037/atm.2019.08.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Refractory septic shock is a serious disorder with high mortality. There is currently limited evidence to support the use of extracorporeal membrane oxygenation (ECMO) in adult septic shock. We describe the outcome of patients with refractory septic shock in our hospital and try to identify prognostic factors. Methods We studied a total of 23 (14 males and 9 females) refractory septic shock patients treated with venoarterial (VA) ECMO in our hospital. Clinical parameters of survival and death groups, laboratory parameters before and after ECMO placement were analyzed. Results Eight patients were successfully weaned off ECMO and five patients were discharged. The sepsis-related organ failure assessment (SOFA) score and shock-to-ECMO interval before ECMO placement in the survival group were significantly lower than those in the death group (12.0 vs. 15.0, P=0.007; 23.5 vs. 42.2 h, P=0.037). The number of cases who had the normal range of ScvO2% between the survival group and the death group at 12 h (4 vs. 4, P=0.033), 18 h (5 vs. 7, P=0.016) and 24 h (5 vs. 9, P=0.043) during ECMO was significantly different. In univariate logistic regression analysis, the case of patients with normal central venous oxygen saturation (ScvO2) % at 12 h during ECMO [odds ratio (OR) 14.0, 95% confidence interval (CI): 1.200-163.367, P=0.035] was significantly associated with risk of the prognosis of patients. Conclusions In adult refractory septic shock patients, ScvO2% at 12 h during ECMO may be a risk factor for patient prognosis.
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Affiliation(s)
- Lei Han
- Medical and Education Department, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Yan Zhang
- Critical Care Medicine, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Yonghui Zhang
- Critical Care Medicine, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Wei Wu
- Thoracic Surgery Department, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Ping He
- Cardiac Surgery Department, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
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14
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Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Applied Uses of Extracorporeal Membrane Oxygenation Therapy. Cureus 2019; 11:e5163. [PMID: 31341752 PMCID: PMC6639062 DOI: 10.7759/cureus.5163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.
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Affiliation(s)
- Avani R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Amar R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Shivank Singh
- Internal Medicine, Southern Medical University, Guangzhou, CHN
| | - Shantanu Singh
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
| | - Imran Khawaja
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
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15
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Simoni J. Why do we need extracorporeal blood purification for sepsis and septic shock? Artif Organs 2019; 43:444-447. [DOI: 10.1111/aor.13442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/19/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Jan Simoni
- Texas HemoBioTherapeutics & BioInnovation Center Lubbock Texas
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16
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Choi MS, Sung K, Cho YH. Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Korean Circ J 2019; 49:657-677. [PMID: 31364329 PMCID: PMC6675698 DOI: 10.4070/kcj.2019.0188] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/24/2019] [Indexed: 12/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technique that uses a pump to drain blood from a body, circulate blood through a membrane lung, and return the oxygenated blood back into the body. Venoarterial (VA) ECMO is a simplified version of the heart-lung machine that assists native pulmonary and/or cardiac function. VA ECMO is composed of a drainage cannula in the venous system and a return cannula in the arterial system. Because VA ECMO can increase tissue perfusion by increasing the arterial blood flow, it is used to treat medically refractory cardiogenic shock or cardiac arrest. VA ECMO has a distinct physiology that is referred to as differential flows. It can cause several complications such as left ventricular distension with pulmonary edema, distal limb ischemia, bleeding, and thromboembolism. Physicians who are using this technology should be knowledgeable on the prevention and management of these complications. We review the basic physiology of VA ECMO, the mechanism of complications, and the simple management of VA ECMO.
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Affiliation(s)
- Min Suk Choi
- Department of Thoracic and Cardiovascular Surgery, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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