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Le Pape S, Joly F, Arrivé F, Frat JP, Rodriguez M, Joos M, Marchasson L, Wairy M, Thille AW, Coudroy R. Factors associated with decreased compliance after on-site extracorporeal membrane oxygenation cannulation for acute respiratory distress syndrome: A retrospective, observational cohort study. JOURNAL OF INTENSIVE MEDICINE 2024; 4:194-201. [PMID: 38681786 PMCID: PMC11043634 DOI: 10.1016/j.jointm.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) is systematically associated with decreased respiratory system compliance (CRS). It remains unclear whether transportation to the referral ECMO center, changes in ventilatory mode or settings to achieve ultra-protective ventilation, or the natural evolution of ARDS drives this change in respiratory mechanics. Herein, we assessed the precise moment when CRS decreases after ECMO cannulation and identified factors associated with decreased CRS. Methods To rule out the effect of transportation and the different modes of ventilation on CRS, we conducted a retrospective, single-center, observational cohort study from January 2013 to May 2020, on 22 patients with severe ARDS requiring on-site ECMO and ventilated in pressure-controlled mode to achieve ultra-protective ventilation. CRS was assessed at different time points ranging from 12 h before ECMO cannulation to 72 h after ECMO cannulation. The primary outcome was the relative change in CRS between 3 h before and 3 h after ECMO cannulation. The secondary outcomes included variables associated with the relative changes in CRS within the first 3 h after ECMO cannulation and the relative changes in CRS at each time point. Results CRS decreased within the first 3 h after ECMO cannulation (-28.3%, 95% confidence interval [CI]: -38.8 to -17.9, P<0.001), while the decrease was mild before and after these first 3 h after ECMO cannulation. To achieve ultra-protective ventilation, respiratory rate decreased in the mean by -13 breaths/min (95% CI: -15 to -11) and driving pressure by -8.3 cmH2O (95% CI: -11.2 to -5.3), resulting in decreased tidal volume by -3.3 mL/kg of predicted body weight (95% CI: -3.9 to -2.6) as compared to before ECMO cannulation (P <0.001 for all). Plateau pressure reduction, driving pressure reduction, and tidal volume reduction were significantly associated with decreased CRS after ECMO cannulation, whereas neither respiratory rate, positive end-expiratory pressure, inspired fraction of oxygen, fluid balance, nor mean airway pressure was associated with decreased CRS. Conclusions Decreased driving pressure resulting in lower tidal volume to achieve ultra-protective ventilation after ECMO cannulation was associated with a marked decrease in CRS in ARDS patients with on-site ECMO cannulation.
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Affiliation(s)
- Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Florent Joly
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Maeva Rodriguez
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maïa Joos
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Mathilde Wairy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W. Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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Trejnowska E, Skoczyński S, Swinarew AS, Tarczyńska-Słomian M, Armatowicz P, Cyprys P, Cieśla D, Zembala MO, Knapik P, Hryniewicz K. Value, time and outcomes of elevated lactate levels in adult patients on extracorporeal membrane oxygenation. Perfusion 2024; 39:124-133. [PMID: 36168831 DOI: 10.1177/02676591221130177] [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: 11/16/2022]
Abstract
INTRODUCTION Lactate levels have been recognized as a reliable tool for monitoring critically ill patients requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) or venovenous extracorporeal membrane oxygenation (VV ECMO) but the reasons behind the overproduction of lactate are different and the influance for survival remains controversial. We analyzed the lactate values and lactate clearance in adult patients in these two forms of extracorporeal support. METHODS Patient demographics, ECMO duration, 30-day mortality, lactate values and lactate clearance at 24, 48 and 72 h from ECMO initiation of patients supported with VV and VA ECMO at Silesian Centre for Heart Deasese, between January 2011 and April 2020 were retrospectively analyzed. The changes in lactate levels were analyzed using the non-parametric U Mann-Whitney tests and Chi-square test. The ROC curves were draw and the area under the curve was calculated. RESULTS The study comprised 91 adult patients, Mortality in the first 30 days from initiation of VV and VA ECMO was 39% and 66%, respectively. Lactate levels were significantly higher in non-survivors that received VV and VA ECMO (p < .001), while lactate clearance was similar (p = .256 and p = 1.000, respectively). Survival curves for patients with elevated (>2.0 mmol/L) vs normal (≤2.0 mmol/L) lactate levels at 72 h were significantly different for VV ECMO (p = .007) and VA ECMO (p = .037) but in both groups of ECMO, lactate levels above 2.0 mmol/L at 72 h from ECMO initiation predicted 30 day-mortality. CONCLUSION This results emphasized the importance of lactate levels below 2.0 mmol/L at 72 h from both VV and VA ECMO initiation.
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Affiliation(s)
- Ewa Trejnowska
- Clinical Department of Cardioanesthesia and Intensive Care Unit, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Szymon Skoczyński
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Andrzej S Swinarew
- Faculty of Science and Technology, University of Silesia, Katowice, Poland
- Department of Individual Sports, Institute of Sport Science, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Magda Tarczyńska-Słomian
- III Clinical Department of Cardiology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Paul Armatowicz
- Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Cyprys
- Doctoral School, Clinical Department of Cardioanesthesiology and Intensive Care Unit, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies,Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Michał O Zembala
- Department of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Center For Heart Diseases, Zabrze, Poland
- Pomeranian Medical University, Szczecin, Poland
| | - Piotr Knapik
- Clinical Department of Cardioanesthesia and Intensive Care Unit, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Katarzyna Hryniewicz
- Minneapolis Heart Institute Section of Advanced Heart Failure/MCS/ Heart Transplantation, Abbott Northwestern Hospital Minneapolis, MN, USA
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Ruiz-Rodríguez JC, Molnar Z, Deliargyris EN, Ferrer R. The Use of CytoSorb Therapy in Critically Ill COVID-19 Patients: Review of the Rationale and Current Clinical Experiences. Crit Care Res Pract 2021; 2021:7769516. [PMID: 34336280 PMCID: PMC8324379 DOI: 10.1155/2021/7769516] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/08/2021] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic has led to the biggest global health crisis of our lifetime. There is accumulating evidence that a substantial number of critically ill COVID-19 patients exhibit a dysregulated host response manifesting as cytokine storm or cytokine release syndrome, which in turn contributes to the high observed rates of mortality. Just as in other hyperinflammatory conditions, extracorporeal cytokine removal may have potential beneficial effects in this subgroup of COVID-19 patients. The CytoSorb blood purification device is the most extensively investigated cytokine removal platform with considerable evidence suggesting that early intervention can provide rapid hemodynamic stabilization and improvement in vital organ functions. The purpose of this review is to provide an overview of the pathophysiological background of hyperinflammation in COVID-19 and to summarize the currently available evidence on the effects of hemoadsorption in these patients.
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Affiliation(s)
- Juan Carlos Ruiz-Rodríguez
- Department of Intensive Care, Hospital Universitari Vall d'Hebron, Shock Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Zsolt Molnar
- CytoSorbents Europe GmbH, Berlin, Germany
- Institute for Translational Medicine, School of Medicine, University of Pécs, Pécs, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Ricard Ferrer
- Department of Intensive Care, Hospital Universitari Vall d'Hebron, Shock Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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Spinelli E, Colussi G, Dal Santo G, Scotti E, Marongiu I, Garbelli E, Mazzucco A, Dondossola D, Maia R, Battistin M, Biancolilli O, Rosso L, Gatti S, Mauri T. Atelectasis, Shunt, and Worsening Oxygenation Following Reduction of Respiratory Rate in Healthy Pigs Undergoing ECMO: An Experimental Lung Imaging Study. Front Physiol 2021; 12:663313. [PMID: 33897471 PMCID: PMC8063114 DOI: 10.3389/fphys.2021.663313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/04/2021] [Indexed: 12/21/2022] Open
Abstract
Rationale: Reducing the respiratory rate during extracorporeal membrane oxygenation (ECMO) decreases the mechanical power, but it might induce alveolar de-recruitment. Dissecting de-recruitment due to lung edema vs. the fraction due to hypoventilation may be challenging in injured lungs. Objectives: We characterized changes in lung physiology (primary endpoint: development of atelectasis) associated with progressive reduction of the respiratory rate in healthy animals on ECMO. Methods: Six female pigs underwent general anesthesia and volume control ventilation (Baseline: PEEP 5 cmH2O, Vt 10 ml/kg, I:E = 1:2, FiO2 0.5, rate 24 bpm). Veno-venous ECMO was started and respiratory rate was progressively reduced to 18, 12, and 6 breaths per minute (6-h steps), while all other settings remained unchanged. ECMO blood flow was kept constant while gas flow was increased to maintain stable PaCO2. Measurements and Main Results: At Baseline (without ECMO) and toward the end of each step, data from quantitative CT scan, electrical impedance tomography, and gas exchange were collected. Increasing ECMO gas flow while lowering the respiratory rate was associated with an increase in the fraction of non-aerated tissue (i.e., atelectasis) and with a decrease of tidal ventilation reaching the gravitationally dependent lung regions (p = 0.009 and p = 0.018). Intrapulmonary shunt increased (p < 0.001) and arterial PaO2 decreased (p < 0.001) at lower rates. The fraction of non-aerated lung was correlated with longer expiratory time spent at zero flow (r = 0.555, p = 0.011). Conclusions: Progressive decrease of respiratory rate coupled with increasing CO2 removal in mechanically ventilated healthy pigs is associated with development of lung atelectasis, higher shunt, and poorer oxygenation.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Colussi
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaia Dal Santo
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Eleonora Scotti
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ines Marongiu
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Erica Garbelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandra Mazzucco
- Thoracic Surgery and Lung Transplantation Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Dondossola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,General and Liver Transplant Surgery Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Raquel Maia
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Intensive Care Medicine, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Michele Battistin
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Thoracic Surgery and Lung Transplantation Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Twelve years of circulatory extracorporeal life support at the University Medical Centre Utrecht. Neth Heart J 2021; 29:394-401. [PMID: 33675521 PMCID: PMC8271054 DOI: 10.1007/s12471-021-01552-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 01/30/2023] Open
Abstract
Introduction Circulatory extracorporeal life support (ECLS) has been performed at the University Medical Centre Utrecht for 12 years. During this time, case mix, indications, ECLS set-ups and outcomes seem to have substantially changed. We set out to describe these characteristics and their evolution over time. Methods All patients receiving circulatory ECLS between 2007 and 2018 were retrospectively identified and divided into six groups according to a 2-year period of time corresponding to the date of ECLS initiation. General characteristics plus data pertaining to comorbidities, indications and technical details of ECLS commencement as well as in-hospital, 30-day, 1‑year and overall mortality were collected. Temporal trends in these characteristics were examined. Results A total of 347 circulatory ECLS runs were performed in 289 patients. The number of patients and ECLS runs increased from 8 till a maximum of 40 runs a year. The distribution of circulatory ECLS indications shifted from predominantly postcardiotomy to a wider set of indications. The proportion of peripheral insertions with or without application of left ventricular unloading techniques substantially increased, while in-hospital, 30-day, 1‑year and overall mortality decreased over time. Conclusion Circulatory ECLS was increasingly applied at the University Medical Centre Utrecht. Over time, indications as well as treatment goals broadened, and cannulation techniques shifted from central to mainly peripheral approaches. Meanwhile, weaning success increased and mortality rates diminished. Supplementary Information The online version of this article (10.1007/s12471-021-01552-z) contains supplementary material, which is available to authorized users.
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Ntoumenopoulos G, Buscher H, Scott S. Lung ultrasound score as an indicator of dynamic lung compliance during veno-venous extra-corporeal membrane oxygenation. Int J Artif Organs 2020; 44:194-198. [PMID: 32779510 DOI: 10.1177/0391398820948870] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Decisions on weaning from veno-venous extra-corporeal membrane oxygenation (VV-ECMO) requires the ability to maintain adequate gas exchange and work of breathing with reductions in ECMO pump flow and fresh gas flow. Testing of the readiness to wean the patient from ECMO however may vary dependent upon local protocols and clinical judgment. This study sought to validate the use of the LUS-score during VV-ECMO against the changes in chest x-ray infiltrates, dynamic lung compliance (CLdyn) and VV-ECMO settings (as standard measures of native lung function and the level of ECMO support) during the ECMO cycle. This prospective cohort study of 10 patients on VV-ECMO compared the LUS score (range 0-36) within 48-h, day 5 and day 10 of commencement of ECMO (or on the day of ECMO decannulation) to dynamic lung compliance, Murray Lung Injury Score and ECMO settings. Seven Male and three Female patients were included (average age 37 years (SD 14.8) and weight 71 Kg (SD 16.9). Median (IQR) duration of ECMO, ICU and hospital length of stay was 7.5 days (5.2-19.0), 12.5 days (8.5-22.7), 19.0 days (12.1- 36.1), respectively. There was a strong negative association between LUS-score and dynamic lung compliance (rs(33) = -0.66, p < .001) providing some validation on the use of the LUS score as a potential surrogate measure of lung aeration and lung mechanics during VV-ECMO weaning.
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Affiliation(s)
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Australia.,Centre of Applied Medical Research, University of New South Wales, Australia
| | - Sean Scott
- Department of Intensive Care Medicine, St Vincent's Hospital, Australia.,The University of Notre Dame, Australia
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Spinelli E, Grieco DL, Mauri T. A personalized approach to the acute respiratory distress syndrome: recent advances and future challenges. J Thorac Dis 2019; 11:5619-5625. [PMID: 32030284 DOI: 10.21037/jtd.2019.11.61] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, IRCCS Foundation "Ca' Granda" "Maggiore Policlinico" Hospital, Milan, Italy
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS Foundation "Ca' Granda" "Maggiore Policlinico" Hospital, Milan, Italy
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