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Mazzeffi M, Levy JH. Antithrombin Deficiency during Venoarterial Extracorporeal Membrane Oxygenation: Extremely Common, but Does It Matter? Anesthesiology 2024; 140:1065-1067. [PMID: 38742999 DOI: 10.1097/aln.0000000000004948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Michael Mazzeffi
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virginia
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery Duke University School of Medicine, Durham, North Carolina
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Douflé G, Dragoi L, Morales Castro D, Sato K, Donker DW, Aissaoui N, Fan E, Schaubroeck H, Price S, Fraser JF, Combes A. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med 2024; 50:632-645. [PMID: 38598123 DOI: 10.1007/s00134-024-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Nadia Aissaoui
- Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
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Fischbach A, Lamberti M, Simons JA, Wrede E, Theißen A, Winnersbach P, Rossaint R, Stollenwerk A, Bleilevens C. Early Blood Clot Detection Using Forward Scattering Light Measurements Is Not Superior to Delta Pressure Measurements. BIOSENSORS 2023; 13:1012. [PMID: 38131772 PMCID: PMC10741584 DOI: 10.3390/bios13121012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
The occurrence of thrombus formation within an extracorporeal membrane oxygenator is a common complication during extracorporeal membrane oxygenation therapy and can rapidly result in a life-threatening situation due to arterial thromboembolism, causing stroke, pulmonary embolism, and limb ischemia in the patient. The standard clinical practice is to monitor the pressure at the inlet and outlet of oxygenators, indicating fulminant, obstructive clot formation indicated by an increasing pressure difference (ΔP). However, smaller blood clots at early stages are not detectable. Therefore, there is an unmet need for sensors that can detect blood clots at an early stage to minimize the associated thromboembolic risks for patients. This study aimed to evaluate if forward scattered light (FSL) measurements can be used for early blood clot detection and if it is superior to the current clinical gold standard (pressure measurements). A miniaturized in vitro test circuit, including a custom-made test chamber, was used. Heparinized human whole blood was circulated through the test circuit until clot formation occurred. Four LEDs and four photodiodes were placed along the sidewall of the test chamber in different positions for FSL measurements. The pressure monitor was connected to the inlet and the outlet to detect changes in ΔP across the test chamber. Despite several modifications in the LED positions on the test chamber, the FSL measurements could not reliably detect a blood clot within the in vitro test circuit, although the pressure measurements used as the current clinical gold standard detected fulminant clot formation in 11 independent experiments.
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Affiliation(s)
- Anna Fischbach
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (J.A.S.); (A.T.); (P.W.); (R.R.)
| | - Michael Lamberti
- Informatics 11—Embedded Software, RWTH Aachen University, 52074 Aachen, Germany; (M.L.); (E.W.); (A.S.)
| | - Julia Alexandra Simons
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (J.A.S.); (A.T.); (P.W.); (R.R.)
| | - Erik Wrede
- Informatics 11—Embedded Software, RWTH Aachen University, 52074 Aachen, Germany; (M.L.); (E.W.); (A.S.)
| | - Alexander Theißen
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (J.A.S.); (A.T.); (P.W.); (R.R.)
| | - Patrick Winnersbach
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (J.A.S.); (A.T.); (P.W.); (R.R.)
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (J.A.S.); (A.T.); (P.W.); (R.R.)
| | - André Stollenwerk
- Informatics 11—Embedded Software, RWTH Aachen University, 52074 Aachen, Germany; (M.L.); (E.W.); (A.S.)
| | - Christian Bleilevens
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (J.A.S.); (A.T.); (P.W.); (R.R.)
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Wang L, Ni K, Wang Y, Lu H, Fang J, Chen C. Nosocomial infections in adult patients receiving extracorporeal membrane oxygenation in China: A retrospective cohort study. Am J Infect Control 2023; 51:1237-1241. [PMID: 37059121 DOI: 10.1016/j.ajic.2023.04.010] [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: 01/26/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used in China, but nosocomial infections (NI) in patients receiving ECMO remain poorly characterized. Thus, this study aimed to investigate the incidence rate, causative was pathogens, and risk factors of NIs in ECMO patients. METHODS A retrospective cohort study of patients receiving ECMO between January 2015 and October 2021 was conducted in a tertiary hospital. General demographics and clinical data of the included patients were collected from the electronic medical record system and the real-time NI surveillance system. RESULTS A total of 86 infected patients with 110 episodes of NIs were identified in 196 patients receiving ECMO. The incidence of NI was 59.2/1000 ECMO days. The median time for the first NI in ECMO patients was 5 days (interquartile range: 2-8 days). Hospital-acquired pneumonia and bloodstream infections were common types of NIs in ECMO patients, and the main pathogens were gram-negative bacteria. Pre-ECMO invasive mechanical ventilation (OR = 2.40, 95% CI:1.12-5.15) and prolonged duration of ECMO (OR = 1.26, 95% CI:1.15-1.39) were risk factors for NIs during ECMO support. DISCUSSION This study identified the main infection sites and pathogens of NIs in ECMO patients. Although NIs may not affect successful ECMO weaning, additional measures should be implemented to reduce the incidence of NI during ECMO support.
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Affiliation(s)
- Lizhu Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kaiwen Ni
- Department of Infection Control, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Yuwei Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haifei Lu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jue Fang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chengyang Chen
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Jasny T, Kloka J, Old O, Piekarski F, Lotz G, Zacharowski K, Friedrichson B. Results from 237 extracorporeal membrane oxygenation runs with drowned patients: a nationwide retrospective study. Crit Care 2023; 27:293. [PMID: 37474978 PMCID: PMC10360217 DOI: 10.1186/s13054-023-04580-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Drowning is one of the leading causes of death worldwide and presents with a wide range of symptoms, from simple coughing to cardiac or pulmonary failure. In severe cases, extracorporeal membrane oxygenation (ECMO) should be considered as a rescue therapy. Therefore, we sought to analyse ECMO usage, outcomes and predictive factors in drowned patients. METHODS The Federal Statistical Office of Germany provided the study data. The patients included experienced drowning (ICD T75.1) and ECMO (OPS 8-852.0, 8-852.3) between 2007 and 2020. All age groups were included. Mortality was calculated for the total population and for ECMO patients. A multiple logistic regression model for ECMO patients was applied to account for predefined patient characteristics and complications. RESULTS Of 12,354 patients who were hospitalised due to drowning, 237 patients (1.9%) received ECMO. Hospital mortality was 14.1% (n = 1741) overall and 74.7% (n = 177) for ECMO patients. In-hospital mortality was positively associated with cardiopulmonary resuscitation (CPR) before admission (odds ratio [OR] 4.49, 1.31-15.39) and in-hospital CPR (OR 6.28, 2.76-14.31). Stroke (OR 0.14, 0.02-0.96) and drug abuse (OR 0.05, 0.01-0.45) were negatively associated with in-hospital mortality. Neither the ECMO mode nor the patient's age and sex had statistically significant effects on survival. CONCLUSION This study indicates that survival in drowned patients who receive ECMO is lower than previously reported. The proportion of paediatric patients was also smaller than expected. As the effects of different ECMO modes on mortality remain unclear, the need for further study remains great.
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Affiliation(s)
- Thomas Jasny
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Jan Kloka
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Oliver Old
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Florian Piekarski
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Gösta Lotz
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Benjamin Friedrichson
- Goethe University Frankfurt, University Hospital, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany.
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Wieruszewski PM, Ortoleva JP, Cormican DS, Seelhammer TG. Extracorporeal Membrane Oxygenation in Acute Respiratory Failure. Pulm Ther 2023; 9:109-126. [PMID: 36670314 PMCID: PMC9859746 DOI: 10.1007/s41030-023-00214-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a form of mechanical life support that provides full respiratory bypass in patients with severe respiratory failure as a bridge to recovery or lung transplantation. The use of ECMO for respiratory failure and capable centers offering ECMO has expanded over the years, increasing its availability. As VV-ECMO provides an artificial mechanism for oxygenation and decarboxylation of native blood, it allows for an environment in which safer mechanical ventilatory care may be provided, allowing for treatment and resolution of underlying respiratory pathologies. Landmark clinical trials have provided a framework for better understanding patient selection criteria, resource utilization, and outcomes associated with ECMO when applied in settings of refractory respiratory failure. Maintaining close vigilance and management of complications during ECMO as well as identifying strategies post-ECMO (e.g., recovery, transplantation, etc.), are critical to successful ECMO support. In this review, we examine considerations for candidate selection for VV-ECMO, review the evidence of utilizing VV-ECMO in respiratory failure, and provide practical considerations for managing respiratory ECMO patients, including complication identification and management, as well as assessing for the ability to separate from ECMO support and the procedures for decannulation.
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Affiliation(s)
- Patrick M. Wieruszewski
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA ,Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Jamel P. Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA USA
| | - Daniel S. Cormican
- Division of Cardiothoracic Anesthesiology, Allegheny General Hospital, Pittsburg, PA USA
| | - Troy G. Seelhammer
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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