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Chiarini G, Mariani S, Schaefer AK, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Botta L, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, Ramanathan K, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study. Crit Care 2024; 28:265. [PMID: 39113082 PMCID: PMC11304572 DOI: 10.1186/s13054-024-05047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/27/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications. METHODS This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models. RESULTS This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar. CONCLUSIONS In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.
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Affiliation(s)
- Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands.
- Intensive Care Unit, Spedali Civili University Hospital, Brescia, Italy.
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands
- Cardiac Surgery Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Bas C T van Bussel
- Department of Intensive Care Medicine, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery, Karl Landsteiner University, University Clinic St, Pölten, St. Pölten, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Luca Botta
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults and Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurs, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, Department of Cardiovascular Sciences, University of Leuven, Louvain, Belgium
| | - Daniel Herr
- Departments of Medicine and Surgery, University of Maryland, Baltimore, USA
| | - Sacha Matteucci
- SOD Cardiochirurgia Ospedali Riuniti 'Umberto I - Lancisi - Salesi' Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Department of Medicine and Surgery, Cardiac Surgery Unit, University of Parma, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo Per I Trapianti e Terapie Ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- Departamento de Anestesia, ECMO Unit, Clínica Las Condes, Las Condes, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, FL, 33021, USA
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - José P Garcia
- IU Health Advanced Heart and Lung Care, Indiana University Methodist Hospital, Indianapolis, IN, USA
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Glenn J R Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands
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Young T, Ezzat B, Nichols N, Aydin S, Pastuszko P, Morgenstern PF. Managing medically refractory elevated intracranial pressure in a pediatric patient on ECMO: illustrative case. Childs Nerv Syst 2024:10.1007/s00381-024-06549-8. [PMID: 39046474 DOI: 10.1007/s00381-024-06549-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 07/17/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE We demonstrate the complexities of managing pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy requiring neurosurgery, focusing on systemic anticoagulation, cardiac function, and medically refractory intracranial pressure (ICP). METHODS A 3.5-year-old female with Tetralogy of Fallot developed severe ischemic cerebral edema following post-operative cardiac arrest and required ECMO. This case, along with four additional cases of children requiring neurosurgery while on ECMO, was examined. RESULTS Emergency neurosurgical intervention in the primary case led to significant improvement, highlighting the delicate balance between managing ECMO-induced anticoagulation and urgent neurosurgical needs. The additional cases had variable outcomes, emphasizing the challenges of caring for these critically ill patients. CONCLUSION Successful management of children requiring ECMO support and neurosurgical intervention requires thoughtful multidisciplinary care. This report illustrates some of the nuances in such decision-making, and demonstrates one potential path to a good outcome.
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Affiliation(s)
- Tirone Young
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Bahie Ezzat
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Noah Nichols
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Scott Aydin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Pastuszko
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter F Morgenstern
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Akbar AF, Rokui S, Zhou AL, Kilic A, King E, Cho SM. Incidence and Risk Factors for Stroke After Combined Heart-Kidney and Heart-Liver Transplantation. Clin Transplant 2024; 38:e15369. [PMID: 39031709 PMCID: PMC11262467 DOI: 10.1111/ctr.15369] [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: 03/21/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVE While stroke is a well-recognized complication of isolated heart transplantation, stroke in patients undergoing simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) has not been explored. This study assessed postoperative stroke incidence, risk factors, and outcomes in HLT and HKT compared with isolated heart transplant. METHODS The United Network for Organ Sharing database was queried for adult patients undergoing HLT, HKT, and isolated heart transplants between 1994 and 2022. Patients were stratified by presence of in-hospital stroke after transplant. Post-transplant survival at 1-year was assessed using Kaplan-Meier analysis and log-rank tests. Separate multivariable logistic regression models were constructed to identify risk factors for stroke after HKT and HLT. RESULTS Of 2326 HKT recipients, 85 experienced stroke, and of 442 HLT recipients, 19 experienced stroke. Stroke was more common after HKT and HLT than after an isolated heart transplant (3.7% vs. 4.3% vs. 2.9%, p = 0.01). One-year post-transplant survival was lower in those with stroke among both HKT recipients (64.5% vs. 88.7%, p(log-rank) < 0.001) and HLT recipients (43.8% vs. 87.4%, p(log-rank) < 0.001. Pre-transplant pVAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time were independent risk factors for stroke after HKT, after adjusting for age, sex, and need for blood transfusion on the waitlist. For HLT, postoperative dialysis was a significant risk factor. CONCLUSIONS Stroke is more common after HKT and HLT than after isolated heart transplant, and results in poor survival. Independent risk factors for stroke include pre-transplant percutaneous VAD (HKT) and postoperative dialysis (HKT and HLT).
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Affiliation(s)
- Armaan F. Akbar
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sorush Rokui
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Division of Cardiac Surgery, University of British Columbia, Vancouver, Canada
| | - Alice L. Zhou
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Ahmet Kilic
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Elizabeth King
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD
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Siddiqui K, Hafeez MU, Ahmad A, Kazmi SO, Chatterjee S, Bershad E, Hirzallah M, Rao C, Damani R. Multimodal Neurologic Monitoring in Patients Undergoing Extracorporeal Membrane Oxygenation. Cureus 2024; 16:e59476. [PMID: 38826870 PMCID: PMC11140437 DOI: 10.7759/cureus.59476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is associated with a high rate of neurologic complications. Multimodal neurologic monitoring (MNM) has the potential for early detection and intervention. We examined the safety and feasibility of noninvasive MNM during ECMO. We hypothesized that survivors and non-survivors would have meaningful differences in transcranial Doppler (TCD) sonography and electroencephalographic (EEG) characteristics, which we aimed to identify. We also investigated adverse neurologic events and attempted to identify differences in EEG and TCD characteristics among patients based on the type of ECMO and the occurrence of these events. Material and methods We performed an observational study on all patients undergoing ECMO at Baylor St. Luke's Medical Center's critical care unit in Houston, Texas, United States, from January 2017 to February 2019. All patients underwent a noninvasive MNM protocol. Results NM was completed in 75% of patients; all patients received at least one component of the monitoring protocol. No adverse events were noted, showing the feasibility and safety of the protocol. The 60.4% of patients who did not survive tended to be older, had lower ejection fractions, and had lower median right middle cerebral artery (MCA) pulsatility and resistivity indexes. Patients undergoing venoarterial (VA)-ECMO had lower median left and right MCA velocities and lower right Lindegaard ratios than patients who underwent venovenous-ECMO. In VA-ECMO patients, EEG less often showed sleep architecture, while other findings were similar between groups. Adverse neurologic events occurred in 24.7% of patients, all undergoing VA-ECMO. Acute ischemic stroke occurred in 22% of patients, intraparenchymal hemorrhage in 4.9%, hypoxic-ischemic encephalopathy in 3.7%, subarachnoid hemorrhage in 2.5%, and subdural hematoma in 1.2%. Conclusion Our results suggest that MNM is safe and feasible for patients undergoing ECMO. Certain EEG and TCD findings could aid in the early detection of neurologic deterioration. MNM may not just be used in monitoring patients undergoing ECMO but also in prognostication and aiding clinical decision-making.
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Affiliation(s)
| | | | - Ali Ahmad
- Neurology, Baylor College of Medicine, Houston, USA
| | - Syed O Kazmi
- Neurology, Salem Health Hospitals & Clinics, Salem, USA
| | | | - Eric Bershad
- Neurology, Baylor College of Medicine, Houston, USA
| | | | - Chethan Rao
- Neurocritical Care, Baylor College of Medicine, Houston, USA
| | - Rahul Damani
- Neurology, Baylor College of Medicine, Houston, USA
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Geetha S, Verma N, Chakole V. A Comprehensive Review of Extra Corporeal Membrane Oxygenation: The Lifeline in Critical Moments. Cureus 2024; 16:e53275. [PMID: 38435953 PMCID: PMC10905309 DOI: 10.7759/cureus.53275] [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: 11/26/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has evolved into a pivotal intervention in critical care, offering a lifeline for patients facing severe respiratory or cardiac failure. This review provides a comprehensive exploration of ECMO, spanning its definition and historical background to its contemporary advancements and ongoing impact in critical care. The versatility of ECMO in addressing diverse critical conditions, careful patient selection criteria, and the nuanced management of complications are discussed. Advances in technology, including miniaturization, novel circuit designs, and the integration of remote monitoring, showcase the evolving landscape of ECMO. The review underscores the ongoing impact of ECMO in improving survival rates, enhancing mobility, and enabling remote expertise. As a symbol of hope and innovation, ECMO's lifesaving potential is evident in its ability to navigate the complexities of critical care and redefine the boundaries of life support interventions.
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Affiliation(s)
- Sindhu Geetha
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neeta Verma
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek Chakole
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Akbar AF, Shou BL, Casillan AJ, Kilic A, Bush EL, Whitman G, Cho SM. Incidence, risk factors, and outcomes of postoperative stroke in combined heart-lung transplantation: A retrospective cohort study of the UNOS registry. Clin Transplant 2024; 38:e15207. [PMID: 38041483 DOI: 10.1111/ctr.15207] [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: 09/13/2023] [Revised: 11/06/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
Stroke is a well-characterized complication of isolated heart and lung transplantation, but has not been described in combined heart-lung transplantation (HLTx). We retrospectively reviewed national U.S. data to describe the incidence, risk factors, and impact of postoperative stroke in HLTx recipients. Of 871 heart-lung recipients between 1994-2022, 35 (4.0%) experienced stroke, and the incidence increased over time, trending toward significance (p-trend = .07). After adjustment, extracorporeal membrane oxygenation (ECMO) (Adjusted odds ratio [aOR] = 2.63, 95%CI = [1.13-6.11]) and pre-transplant implantable defibrillator (aOR = 2.86, 95%CI = [1.20-6.81]) were independent risk factors for stroke. Postoperative stroke is common and is increasing in an era where organ allocation is driven by mechanical circulatory support (MCS) bridging.
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Affiliation(s)
- Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alfred J Casillan
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Burzyńska M, Uryga A, Kasprowicz M, Czosnyka M, Goździk W, Robba C. Cerebral Autoregulation, Cerebral Hemodynamics, and Injury Biomarkers, in Patients with COVID-19 Treated with Veno-Venous Extracorporeal Membrane Oxygenation. Neurocrit Care 2023; 39:425-435. [PMID: 36949359 PMCID: PMC10033181 DOI: 10.1007/s12028-023-01700-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/14/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND This study aimed to describe the cerebrovascular dynamics, in particular cerebral autoregulation (CA), and cerebral biomarkers as neuron-specific enolase (NSE) in patients with a diagnosis of coronavirus disease 2019 and acute respiratory distress syndrome as well as undergoing veno-venous extracorporeal membrane treatment. METHODS This was a single center, observational study conducted in the intensive care unit of the University Hospital in Wroclaw from October 2020 to February 2022. Transcranial Doppler recordings of the middle cerebral artery conducted for at least 20 min were performed. Cerebral autoregulation (CA) was estimated by using the mean velocity index (Mxa), calculated as the moving correlation coefficient between slow-wave oscillations in cerebral blood flow velocity and arterial blood pressure. Altered CA was defined as a positive Mxa. Blood samples for the measurement of NSE were obtained at the same time as transcranial Doppler measurements. RESULTS A total of 16 patients fulfilled the inclusion criteria and were enrolled in the study. The median age was 39 (34-56) years. Altered CA was found in 12 patients, and six out of seven patients who died had altered CA. A positive Mxa was a significant predictor of mortality, with a sensitivity of 85.7%. We found that three out of five patients with pathological changes in brain computed tomography and six out of ten patients with neurological complications had altered CA. NSE was a significant predictor of mortality (cutoff value: 28.9 µg/L); area under the curve = 0.83, p = 0.006), with a strong relationship between increased level of NSE and altered CA, χ2 = 6.24; p = 0.035; φ = 0.69. CONCLUSIONS Patients with coronavirus disease 2019-related acute respiratory distress syndrome, requiring veno-venous extracorporeal membrane treatment, are likely to have elevated NSE levels and altered CA. The CA was associated with NSE values in this group. This preliminary analysis suggests that advanced neuromonitoring and evaluation of biomarkers should be considered in this population.
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Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370, Wroclaw, Poland.
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370, Wroclaw, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Chiara Robba
- IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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Carlhan-Ledermann A, Bartoli A, Gebistorf F, Beghetti M, Sologashvili T, Rebollo Polo M, Fluss J. Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review. Childs Nerv Syst 2023; 39:2377-2389. [PMID: 37493722 PMCID: PMC10432330 DOI: 10.1007/s00381-023-06086-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Malignant stroke is a life-threatening emergency, with a high mortality rate (1-3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. METHODS AND RESULTS We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. CONCLUSION Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.
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Affiliation(s)
- Audrey Carlhan-Ledermann
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrea Bartoli
- Neurosurgery Unit, Department of Clinical Neuroscience, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fabienne Gebistorf
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Cardiovascular Surgery Unit, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Monica Rebollo Polo
- Pediatric Radiology Unit, Department of Radiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joel Fluss
- Pediatric Neurology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Shariff M, Dobariya A, Albaghdadi O, Awkal J, Moussa H, Reyes G, Syed M, Hart R, Longfellow C, Douglass D, El Ahmadieh TY, Good LB, Jakkamsetti V, Kathote G, Angulo G, Ma Q, Brown R, Dunbar M, Shelton JM, Evers BM, Patnaik S, Hoffmann U, Hackmann AE, Mickey B, Peltz M, Jessen ME, Pascual JM. Maintenance of pig brain function under extracorporeal pulsatile circulatory control (EPCC). Sci Rep 2023; 13:13942. [PMID: 37626089 PMCID: PMC10457326 DOI: 10.1038/s41598-023-39344-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Selective vascular access to the brain is desirable in metabolic tracer, pharmacological and other studies aimed to characterize neural properties in isolation from somatic influences from chest, abdomen or limbs. However, current methods for artificial control of cerebral circulation can abolish pulsatility-dependent vascular signaling or neural network phenomena such as the electrocorticogram even while preserving individual neuronal activity. Thus, we set out to mechanically render cerebral hemodynamics fully regulable to replicate or modify native pig brain perfusion. To this end, blood flow to the head was surgically separated from the systemic circulation and full extracorporeal pulsatile circulatory control (EPCC) was delivered via a modified aorta or brachiocephalic artery. This control relied on a computerized algorithm that maintained, for several hours, blood pressure, flow and pulsatility at near-native values individually measured before EPCC. Continuous electrocorticography and brain depth electrode recordings were used to evaluate brain activity relative to the standard offered by awake human electrocorticography. Under EPCC, this activity remained unaltered or minimally perturbed compared to the native circulation state, as did cerebral oxygenation, pressure, temperature and microscopic structure. Thus, our approach enables the study of neural activity and its circulatory manipulation in independence of most of the rest of the organism.
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Affiliation(s)
- Muhammed Shariff
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Aksharkumar Dobariya
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Obada Albaghdadi
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Jacob Awkal
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Hadi Moussa
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Gabriel Reyes
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Mansur Syed
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Robert Hart
- The Erik Jonsson School of Engineering and Computer Science, The University of Texas at Dallas, Richardson, TX, 75080, USA
| | - Cameron Longfellow
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Debra Douglass
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, CA, 92354, USA
| | - Levi B Good
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Vikram Jakkamsetti
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Gauri Kathote
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Gus Angulo
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Qian Ma
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA
| | - Ronnie Brown
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Misha Dunbar
- Animal Resource Center, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - John M Shelton
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Bret M Evers
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Sourav Patnaik
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ulrike Hoffmann
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Amy E Hackmann
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Heart and Vascular Center Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Bruce Mickey
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Juan M Pascual
- Rare Brain Disorders Program, Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8813, Dallas, TX, 75390-8813, USA.
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
- Eugene McDermott Center for Human Growth and Development/Center for Human Genetics, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
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10
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Valerianova A, Mlcek M, Kittnar O, Grus T, Tejkl L, Lejsek V, Malik J. A large arteriovenous fistula steals a considerable part of systemic blood flow during veno-arterial extracorporeal circulation support in a porcine model. Front Physiol 2023; 14:1109524. [PMID: 37497434 PMCID: PMC10366375 DOI: 10.3389/fphys.2023.1109524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/30/2023] [Indexed: 07/28/2023] Open
Abstract
Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is one of the most frequently used mechanical circulatory support devices. Distribution of extracorporeal membrane oxygenation flow depends (similarly as the cardiac output distribution) on regional vascular resistance. Arteriovenous fistulas (AVFs), used frequently as hemodialysis access, represent a low-resistant circuit which steals part of the systemic perfusion. We tested the hypothesis that the presence of a large Arteriovenous fistulas significantly changes organ perfusion during a partial and a full Veno-arterial extracorporeal membrane oxygenation support. Methods: The protocol was performed on domestic female pigs held under general anesthesia. Cannulas for Veno-arterial extracorporeal membrane oxygenation were inserted into femoral artery and vein. The Arteriovenous fistulas was created using another two high-diameter extracorporeal membrane oxygenation cannulas inserted in the contralateral femoral artery and vein. Catheters, flow probes, flow wires and other sensors were placed for continuous monitoring of haemodynamics and organ perfusion. A stepwise increase in extracorporeal membrane oxygenation flow was considered under beating heart and ventricular fibrillation (VF) with closed and opened Arteriovenous fistulas. Results: Opening of a large Arteriovenous fistulas (blood flow ranging from 1.1 to 2.2 L/min) resulted in decrease of effective systemic blood flow by 17%-30% (p < 0.01 for all steps). This led to a significant decrease of carotid artery flow (ranging from 13% to 25% after Arteriovenous fistulas opening) following VF and under partial extracorporeal membrane oxygenation support. Cerebral tissue oxygenation measured by near infrared spectroscopy also decreased significantly in all steps. These changes occurred even with maintained perfusion pressure. Changes in coronary artery flow were driven by changes in the native cardiac output. Conclusion: A large arteriovenous fistula can completely counteract Veno-arterial extracorporeal membrane oxygenation support unless maximal extracorporeal membrane oxygenation flow is applied. Cerebral blood flow and oxygenation are mainly compromised by the effect of the Arteriovenous fistulas. These effects could influence brain function in patients with Arteriovenous fistulas on Veno-arterial extracorporeal membrane oxygenation.
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Affiliation(s)
- A. Valerianova
- Third Department of Internal Medicine, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - M. Mlcek
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - O. Kittnar
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - T. Grus
- Second Surgical Clinic—Cardiovascular Surgery, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
| | - L. Tejkl
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - V. Lejsek
- Third Department of Internal Medicine, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
| | - J. Malik
- Third Department of Internal Medicine, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
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11
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Agha HM, Fathalla A, Isgro G, Cotza M. Predictors of Neurological Complications of Pediatric Post-Cardiotomy Extracorporeal Life Support. J Saudi Heart Assoc 2023; 34:249-256. [PMID: 36816795 PMCID: PMC9930983 DOI: 10.37616/2212-5043.1324] [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: 10/28/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
Background Post-cardiotomy extracorporeal membrane oxygenation (ECMO) was associated with significant neurological complications affecting the overall outcome. The aim of the work is to determine the incidence and the predictors of neurological events during pediatric extracorporeal life support after cardiac surgery. Patients & Methods This is a retrospective study that encompassed all neonates, infants, and children (<18 years of age) who need extracorporeal life support following cardiac surgery between January 2015 and December 2018 at San Donato Hospital, Italy. Data as regards surgical procedure of congenital heart disease, in-hospital mortality, length of ECMO, hospital stay durations, short-term neurological ECMO complications and outcome were analyzed. Results The sixty-three patients who received post-cardiotomy ECMO, Neurological complications were evident in 31.7% in the form of ischemic stroke in 17.5% and hemorrhagic stroke in 11.1%. By multivariable analysis, the older age of cyanotic cases, the need for a venting cannula, and the rapid CO2 drop in the first 24 h were the most independent risk factors for neurological complications. Prolonged ECMO support and hospital stay duration were associated with neurological sequelae. Conclusion Neurological complications either ischemic or hemorrhagic strokes were common during pediatric post-cardiotomy ECMO and were significantly related to prolonged ECMO support and hospital stay. Predictors of these neurological sequelae are the older cyanotic cases, the need for a venting cannula, the oxygenator thrombosis, and the rapid CO2 drop in the first 24 h of ECMO.
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Affiliation(s)
- Hala M. Agha
- Department of Pediatrics, Pediatric Cardiology Division, Specialized Pediatric Hospital, Cairo University,
Egypt,Corresponding author at: Pediatric Department, Pediatric Cardiology Division, Specialized Pediatric Hospital, Faculty of Medicine, Cairo University. Kasr Al Aini Street, Cairo, 11562, Egypt. E-mail address: (H.M. Agha)
| | - Amr Fathalla
- Department of Pediatrics, Pediatric Cardiology Division, Specialized Pediatric Hospital, Cairo University,
Egypt
| | - Giuseppe Isgro
- Anaesthesia and Intensive Care Department, IRCCS, Policlinico San Donato, Milan,
Italy
| | - Mauro Cotza
- ECMO/ECLS Unit, IRCCS, Policlinico San Donato, Milan,
Italy
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12
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Aboul-Nour H, Jumah A, Abdulla H, Sharma A, Howell B, Jayaprakash N, Gardner-Gray J. Neurological monitoring in ECMO patients: current state of practice, challenges and lessons. Acta Neurol Belg 2023; 123:341-350. [PMID: 36701079 PMCID: PMC9878494 DOI: 10.1007/s13760-023-02193-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) in critically ill patients serves as a management option for end-stage cardiorespiratory failure in medical and surgical conditions. Patients on ECMO are at a high risk of neurologic adverse events including intracranial hemorrhage (ICH), acute ischemic stroke (AIS), seizures, diffuse cerebral edema, and hypoxic brain injury. Standard approaches to neurological monitoring for patients receiving ECMO support can be challenging for multiple reasons, including the severity of critical illness, deep sedation, and/or paralysis. This narrative literature review provides an overview of the current landscape for neurological monitoring in this population. METHODS A literature search using PubMed was used to aid the understanding of the landscape of published literature in the area of neurological monitoring in ECMO patients. RESULTS Review articles, cohort studies, case series, and individual reports were identified. A total of 73 varied manuscripts were summarized and included in this review which presents the challenges and strategies for performing neurological monitoring in this population. CONCLUSION Neurological monitoring in ECMO is an area of interest to many clinicians, however, the literature is limited, heterogenous, and lacks consensus on the best monitoring practices. The evidence for optimal neurological monitoring that could impact clinical decisions and functional outcomes is lacking. Additional studies are needed to identify effective measures of neurological monitoring while on ECMO.
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Affiliation(s)
- Hassan Aboul-Nour
- grid.189967.80000 0001 0941 6502Department of Neurology, Emory University, Atlanta, GA USA ,grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Ammar Jumah
- grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Hafsa Abdulla
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Amreeta Sharma
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Bradley Howell
- grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Namita Jayaprakash
- grid.413103.40000 0001 2160 8953Department of Emergency Medicine, Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Jayna Gardner-Gray
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA ,grid.413103.40000 0001 2160 8953Department of Emergency Medicine, Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
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13
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Uddin S, Anandanadesan R, Trimlett R, Price S. Intensive Care Management of the Cardiogenic Shock Patient. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Optimal management of patients with cardiogenic shock requires a detailed and systematic assessment of all organ systems, balancing the risks and benefits of any investigation and intervention, while avoiding the complications of critical illness. Overall prognosis depends upon a number of factors, including that of the underlying cardiac disease and its potential reversibility, the severity of shock, the involvement of other organ systems, the age of the patient and comorbidities. As with all intensive care patients, the mainstay of management is supportive, up to and including implementation and management of a number of devices, including acute mechanical circulatory support. The assessment and management of these most critically ill patients therefore demands in-depth knowledge and skill relating to cardiac intensive care, extending well beyond standard intensive care or cardiology practice.
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Affiliation(s)
- Shahana Uddin
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Rathai Anandanadesan
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Richard Trimlett
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Susanna Price
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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14
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Dandapat S, Guerrero WR, Ortega-Gutierrez S. Acute StrokeTreatment in Children: Are Adult Guidelines Applicable? Curr Treat Options Neurol 2022; 24:41-54. [PMID: 35509674 PMCID: PMC9060549 DOI: 10.1007/s11940-022-00707-6] [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: 11/29/2022]
Abstract
Purpose of this Review This article provides an overview into acute treatments in stroke which are widely studied and available for adults and their applicability in the pediatric population. Recent Findings Arterial ischemic stroke is an important cause of morbidity and mortality in the pediatric population. Neurological deficits and etiologies are age-dependent and more challenging to diagnose than in the adult population. Advancements in imaging and treatment modalities including increased treatment windows in acute stroke have led to improvement in the diagnosis and management of pediatric arterial ischemic disease. Accordingly, hyperacute treatments, such as endovascular therapy, are becoming increasingly available in an attempt to improve outcomes in children. Summary Significant scientific and technological advances have transformed the hyperacute treatment of stroke in the recent years, allowing for improvement in the diagnosis and treatment of cerebrovascular pathologies in children. Optimization in the approach, and validation of existing stroke pathways/protocols is expected to further advance acute stroke therapy in pediatric patient care. Given that the lifelong individual, family, and societal burden of acute stroke is likely to be greater than in adults because infants and children surviving stroke live more years with disability, we must be knowledgeable about this pathology and the medical and therapeutic options available for this unique population as detailed in this review.
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Affiliation(s)
- Sudeepta Dandapat
- Department of Neurosciences, Aurora Neuroscience Innovation Institute, St.Luke’s Hospital, Milwaukee, WI
| | - Waldo R. Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Radiology and Neurosurgery, University of Iowa Comprehensive Stroke Center, Iowa City, IA
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15
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Tuan TA, Xoay TD, Phuc PH, Hung DV, Dung NT, Truong NLT, Thuan NV, Dien TM. Pediatric Acute Myocarditis With Short-Term Outcomes and Factors for Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study in Vietnam. Front Cardiovasc Med 2021; 8:741260. [PMID: 34912858 PMCID: PMC8666974 DOI: 10.3389/fcvm.2021.741260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/02/2021] [Indexed: 12/18/2022] Open
Abstract
Objective: Data on the management and outcomes of acute myocarditis treated with extracorporeal membrane oxygenation (ECMO) among low- and middle-income countries are limited. This study aimed to determine the short-term outcomes and also identify factors associated with ECMO use among children with acute myocarditis at a tertiary children's hospital in Vietnam. Methods: A single-center, retrospective observational study was conducted between January 2016 and February 2021. Pediatric patients with acute myocarditis, aged 1 month to 16 years, were included. Results: In total, 54 patients (male, 46%; median age, 7 years) with acute myocarditis were included; 37 of them received ECMO support. Thirty percent (16/54) of the patients died, and 12 of them received ECMO. Laboratory variables that differed between survivors and non-survivors included median left ventricular ejection fraction (LVEF) at 48 h (42 vs. 25%; p = 0.001), platelet count (304 g/L [interquartile range (IQR): 243-271] vs. 219 g/L [IQR: 167-297]; p = 0.014), and protein (60 g/dl [IQR: 54-69] vs. 55 [IQR: 50-58]; p = 0.025). Among patients who received ECMO, compared with the survivors, non-survivors had a low LVEF at 48 h (odds ratio (OR), 0.8; 95% confidence interval (CI): 0.6-0.9; p = 0.006) and high vasoactive-inotropic score (OR, 1.0; 95% CI: 1.0-1.0; p = 0.038) and lactate (OR, 2.8; 95% CI, 1.2-6.1; p = 0.013) at 24 h post-ECMO. Conclusions: The case fatality rate among children with acute myocarditis was 30 and 32% among patients requiring ECMO support. Arrhythmia was an indicator for ECMO in patients with cardiogenic shock.
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Affiliation(s)
- Ta Anh Tuan
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam.,Children's Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.,Department of Pediatric, Hanoi Medical University, Hanoi, Vietnam
| | - Tran Dang Xoay
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Phan Huu Phuc
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Dau Viet Hung
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam.,Children's Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Nguyen Trong Dung
- Pediatric Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Nguyen Ly Thinh Truong
- Department of Cardiovascular Surgery, Children Heart Center, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Nguyen Van Thuan
- Surgical Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Tran Minh Dien
- Children's Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.,Surgical Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
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16
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Nishikawa M, Willey J, Takayama H, Kaku Y, Ning Y, Kurlansky PA, Brodie D, Masoumi A, Fried J, Takeda K. Stroke patterns and cannulation strategy during veno-arterial extracorporeal membrane support. J Artif Organs 2021; 25:231-237. [PMID: 34751886 DOI: 10.1007/s10047-021-01300-5] [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] [Received: 04/08/2021] [Accepted: 10/22/2021] [Indexed: 11/27/2022]
Abstract
Stroke has potentially devastating consequences for patients receiving veno-arterial extracorporeal membrane support (VA-ECMO). Arterial cannulation sites for VA-ECMO include the ascending aorta, axillary artery, and femoral artery. However, the influence of cannulation site on stroke risk has not been well described. The purpose of this study was to investigate the association between occurrence and patterns of stroke with ECMO arterial cannulation sites. We retrospectively reviewed 414 consecutive patients who received VA-ECMO support for cardiogenic shock between March 2007 and May 2018. Patients were categorized by cannulation strategy. The rates, subtype and location of strokes as assessed by neuroimaging during and after VA-ECMO support were analyzed. Median age was 61 years (IQR 50-69); 67% were men. 77 patients were cannulated via the ascending aorta (17%), 31 via the axillary artery (7%), and 306 (69%) via the femoral artery. In total, 26 patients (6.3%) developed 30 stroke lesions at a median of 6.0 (IQR 3.1-8.7) days after ECMO cannulation. Ischemic stroke was the most common subtype (64%), followed by hemorrhagic transformation (20%) and hemorrhagic stroke (16%). Location by CT was right hemispheric in 38%, left hemispheric in 24%, bilateral in 21%, and vertebrobasilar in 17%. The incidence of stroke was similar across cannulation strategies: aorta (n = 5, 6.5%), axillary artery (n = 2, 6.5%), and femoral artery (n = 19, 6.2%), (p = 0.99). Incidence of stroke does not appear to differ among patients cannulated via the ascending aorta, axillary artery, or femoral artery. Ischemic stroke was the most common subtype of stroke.
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Affiliation(s)
- Mia Nishikawa
- Department of Surgery, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, New York, NY, 10032, USA.
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA.
| | - Joshua Willey
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, New York, NY, 10032, USA
| | - Yuji Kaku
- Department of Surgery, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, New York, NY, 10032, USA
| | - Yuming Ning
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY, USA
| | - Paul A Kurlansky
- Department of Surgery, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, New York, NY, 10032, USA
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY, USA
| | - Amirali Masoumi
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Justin Fried
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, New York, NY, 10032, USA.
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17
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Luo Y, Gu Q, Wen X, Li Y, Peng W, Zhu Y, Hu W, Xi S. Neurological Complications of Veno-Arterial Extracorporeal Membrane Oxygenation: A Retrospective Case-Control Study. Front Med (Lausanne) 2021; 8:698242. [PMID: 34277671 PMCID: PMC8280317 DOI: 10.3389/fmed.2021.698242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background: To explore the epidemiology, clinical features, risk indicators, and long-term outcomes of neurological complications caused by veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Methods: We retrospectively analyzed 60 adult patients who underwent V-A ECMO support in our unit from February 2012 to August 2020. These patients were separated into the neurological complications group (NC group) and the non-neurological complications group (nNC group). The differences in basic data and ECMO data between the two groups were compared. The data of long-term neurological prognosis were collected by telephone follow-up. Results: Thirty-nine patients (65.0%) had neurological complications. There were significant differences between the two groups in terms of median age, hypertension, median blood urea nitrogen, median troponin I (TNI), median lactic acid, pre-ECMO percutaneous coronary intervention, continuous renal replacement therapy (CRRT), median Sequential Organ Failure Assessment score, median Acute Physiology and Chronic Health Evaluation II score, median peak inspiratory pressure, median positive end expiratory pressure, and median fresh frozen plasma (P < 0.05). The median Intensive Care Unit length of stay (ICU LOS), 28-day mortality, median post-ECMO vasoactive inotropic score, non-pulsate perfusion (NP), and median ECMO duration of the NC group were significantly higher than those of the nNC group (P < 0.05). Furthermore, multiple logistic regression analysis revealed that TNI (P = 0.043), CRRT (P = 0.047), and continuous NP > 12 h (P = 0.043) were independent risk indicators for neurological complications in patients undergoing ECMO. Forty-four patients (73.3%) survived after discharge, and 38 patients (63.3%) had Cerebral Performance Category score of 1–2. And there were significant differences between the two groups in long-term neurological outcomes after discharge for 6 months (P < 0.05). Conclusion: The incidence of neurological complications was higher in patients undergoing V-A ECMO and was closely related to adverse outcomes (including ICU LOS and 28-day mortality). TNI, CRRT, and continuous NP > 12 h were independent risk indicators for predicting neurological complications in ECMO supporting patients. And the neurological complications of patients during ECMO support had significant adverse effect on long-term surviving and neurological outcomes of patients after discharge for 6 months.
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Affiliation(s)
- Yinan Luo
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiao Gu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Wen
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weihua Peng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Zhu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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18
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Martins JF, Cruz LR, Pereira DJ, Sousa JE, Martins P. Posterior reversible encephalopathy syndrome in a patient submitted to extracorporeal membrane oxygenation for COVID-19. Rev Bras Ter Intensiva 2021; 33:457-460. [PMID: 35107558 PMCID: PMC8555388 DOI: 10.5935/0103-507x.20210067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/30/2021] [Indexed: 11/20/2022] Open
Abstract
Uma mulher com 63 anos de idade compareceu ao pronto-socorro com história
aguda de febre, prostração e dispneia. Recebeu diagnóstico
de quadro grave da COVID-19 e síndrome do desconforto respiratório
agudo. Apesar de suporte clínico intensivo, cumpriu os critérios
para ser submetida à oxigenação venovenosa por membrana
extracorpórea. No dia 34, após 7 dias de desmame da
sedação com evolução positiva de seu quadro
neurológico, apresentou uma crise tônico-clônica
generalizada limitada, não relacionada com desequilíbrio
hidroeletrolítico ou metabólico, que levou à necessidade de
investigação diagnóstica. Seus exames de imagem cerebral
revelaram síndrome da encefalopatia posterior reversível. Este
caso enfatiza a questão das complicações
neurológicas em pacientes com COVID-19 grave e a importância do
diagnóstico e suporte precoces.
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Affiliation(s)
- João Francisco Martins
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra - Coimbra, Portugal
| | - Luis Rito Cruz
- Serviço de Imagem Médica, Centro Hospitalar e Universitário de Coimbra - Coimbra, Portugal
| | - Daniela Jardim Pereira
- Serviço de Imagem Médica, Centro Hospitalar e Universitário de Coimbra - Coimbra, Portugal
| | - Jose Eduardo Sousa
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra - Coimbra, Portugal
| | - Paulo Martins
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra - Coimbra, Portugal
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Wei TJ, Wang CH, Chan WS, Huang CH, Lai CH, Wang MJ, Chen YS, Ince C, Lin TY, Yeh YC. Microcirculatory Response to Changes in Venoarterial Extracorporeal Membrane Oxygenation Pump Flow: A Prospective Observational Study. Front Med (Lausanne) 2021; 8:649263. [PMID: 33898485 PMCID: PMC8058194 DOI: 10.3389/fmed.2021.649263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) pump flow is crucial for maintaining organ perfusion in patients with cardiogenic shock, but VA-ECMO pump flow optimization remains as a clinical challenge. This study aimed to investigate the response of sublingual microcirculation to changes in VA-ECMO pump flow. Methods: Sublingual microcirculation was measured before and after changing VA-ECMO pump flow according to the treatment plan of ECMO team within 24 h and at 24-48 h after VA-ECMO placement. In clinical events of increasing VA-ECMO pump flow, those events with increased perfused vessel density (PVD) were grouped into group A, and the others were grouped into group B. In clinical events of decreasing VA-ECMO pump flow, those events with increased PVD were grouped into group C, and the others were grouped into group D. Results: Increased PVD was observed in 60% (95% CI, 38.5–81.5%) of the events with increasing VA-ECMO pump flow. The probability of increasing PVD after increasing VA-ECMO pump flow were higher in the events with a PVD < 15 mm/mm2 at baseline than those with a PVD ≥ 15 mm/mm2 [100% (95% CI, 54.1–100%) vs. 42.9% (95% CI, 17.7–71.1%), P = 0.042]. Other microcirculatory and hemodynamic parameters at baseline did not differ significantly between group A and B or between group C and D. Conclusion: This study revealed contradictory and non-contradictory responses of sublingual microcirculation to changes in VA-ECMO pump flow. Tandem measurements of microcirculation before and after changing VA-ECMO pump flow may help to ensure a good microcirculation.
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Affiliation(s)
- Tzu-Jung Wei
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wing-Sum Chan
- Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Heng Lai
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Jiuh Wang
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Tzu-Yu Lin
- Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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20
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Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review. Curr Treat Options Neurol 2021; 23:15. [PMID: 33814895 PMCID: PMC8009934 DOI: 10.1007/s11940-021-00671-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 01/21/2023]
Abstract
Purpose Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists. Recent findings The most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness. Summary Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.
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21
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Kahl U, Yu Y, Nierhaus A, Frings D, Sensen B, Daubmann A, Kluge S, Fischer M. Cerebrovascular autoregulation and arterial carbon dioxide in patients with acute respiratory distress syndrome: a prospective observational cohort study. Ann Intensive Care 2021; 11:47. [PMID: 33725209 PMCID: PMC7962086 DOI: 10.1186/s13613-021-00831-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/01/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early hypercapnia is common in patients with acute respiratory distress syndrome (ARDS) and is associated with increased mortality. Fluctuations of carbon dioxide have been associated with adverse neurological outcome in patients with severe respiratory failure requiring extracorporeal organ support. The aim of this study was to investigate whether early hypercapnia is associated with impaired cerebrovascular autoregulation during the acute phase of ARDS. METHODS Between December 2018 and November 2019, patients who fulfilled the Berlin criteria for ARDS, were enrolled. Patients with a history of central nervous system disorders, cerebrovascular disease, chronic hypercapnia, or a life expectancy of less than 24 h were excluded from study participation. During the acute phase of ARDS, cerebrovascular autoregulation was measured over two time periods for at least 60 min. Based on the values of mean arterial blood pressure and near-infrared spectroscopy, a cerebral autoregulation index (COx) was calculated. The time with impaired cerebral autoregulation was calculated for each measurement and was compared between patients with and without early hypercapnia [defined as an arterial partial pressure of carbon dioxide (PaCO2) ≥ 50 mmHg with a corresponding arterial pH < 7.35 within the first 24 h of ARDS diagnosis]. RESULTS Of 66 patients included, 117 monitoring episodes were available. The mean age of the study population was 58.5 ± 16 years. 10 patients (15.2%) had mild, 28 (42.4%) moderate, and 28 (42.4%) severe ARDS. Nineteen patients (28.8%) required extracorporeal membrane oxygenation. Early hypercapnia was present in 39 patients (59.1%). Multivariable analysis did not show a significant association between early hypercapnia and impaired cerebrovascular autoregulation (B = 0.023 [95% CI - 0.054; 0.100], p = 0.556). Hypocapnia during the monitoring period was significantly associated with impaired cerebrovascular autoregulation [B = 0.155 (95% CI 0.014; 0.296), p = 0.032]. CONCLUSION Our results suggest that moderate permissive hypercapnia during the acute phase of ARDS has no adverse effect on cerebrovascular autoregulation and may be tolerated to a certain extent to achieve low tidal volumes. In contrast, episodes of hypocapnia may compromise cerebral blood flow regulation. Trial registration ClinicalTrials.gov; registration number: NCT03949738; date of registration: May 14, 2019.
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Affiliation(s)
- Ursula Kahl
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Yuanyuan Yu
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Frings
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Sensen
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Daubmann
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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22
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Feiger B, Adebiyi A, Randles A. Multiscale modeling of blood flow to assess neurological complications in patients supported by venoarterial extracorporeal membrane oxygenation. Comput Biol Med 2020; 129:104155. [PMID: 33333365 DOI: 10.1016/j.compbiomed.2020.104155] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 12/28/2022]
Abstract
Computational blood flow models in large arteries elucidate valuable relationships between cardiovascular diseases and hemodynamics, leading to improvements in treatment planning and clinical decision making. One such application with potential to benefit from simulation is venoarterial extracorporeal membrane oxygenation (VA-ECMO), a support system for patients with cardiopulmonary failure. VA-ECMO patients develop high rates of neurological complications, partially due to abnormal blood flow throughout the vasculature from the VA-ECMO system. To better understand these hemodynamic changes, it is important to resolve complex local flow parameters derived from three-dimensional (3D) fluid dynamics while also capturing the impact of VA-ECMO support throughout the systemic arterial system. As high-resolution 3D simulations of the arterial network remain computationally expensive and intractable for large studies, a validated, multiscale model is needed to compute both global effects and high-fidelity local hemodynamics. In this work, we developed and demonstrated a framework to model hemodynamics in VA-ECMO patients using coupled 3D and one-dimensional (1D) models (1D→3D). We demonstrated the ability of these multiscale models to simulate complex flow patterns in specific regions of interest while capturing bulk flow throughout the systemic arterial system. We compared 1D, 3D, and 1D→3D coupled models and found that multiscale models were able to sufficiently capture both global and local hemodynamics in the cerebral arteries and aorta in VA-ECMO patients. This study is the first to develop and compare 1D, 3D, and 1D→ 3D coupled models on the larger arterial system scale in VA-ECMO patients, with potential use for other large scale applications.
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Affiliation(s)
- Bradley Feiger
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Adebayo Adebiyi
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Amanda Randles
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.
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23
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Abstract
Supplemental Digital Content is available in the text. Objectives: We aimed to determine if elevations in serum neuron-specific enolase are associated with brain injury and outcomes in adults who require venoarterial extracorporeal membrane oxygenation. Design: Prospective observational study. Setting: Two ICUs of a university hospital, Paris, France. Patients: Consecutive adult patients treated with venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock or in-hospital refractory cardiac arrest. Interventions: None. Measurements and Main Results: Serum sampled 1, 3, and 7 days after venoarterial extracorporeal membrane oxygenation cannulation was stored at –80°C and neuron-specific enolase concentrations were measured in batches at the end of the study. The association between neuron-specific enolase concentrations and outcomes (28-d mortality and poor outcome, defined by a score of 4–6 on the modified Rankin scale at 90 d) were explored by multivariable logistic regression, with neuron-specific enolase concentrations dichotomized according to median values. One-hundred three patients were included, of whom 26 (25%) received preextracorporeal membrane oxygenation cardiopulmonary resuscitation. Median (interquartile range) day-1, day-3, and day-7 neuron-specific enolase serum concentrations were 37 μg/L (26–51 μg/L), 25 μg/L (19–37) μg/L, and 22 μg/L (17–31 μg/L). After adjustment for Simplified Acute Physiology Score II, preextracorporeal membrane oxygenation cardiopulmonary resuscitation, and Sepsis Organ Failure Assessment score at time of cannulation, a day-3 neuron-specific enolase greater than 25 μg/L remained independently associated with 28-day mortality (adjusted odds ratio, 4.98; 95% CI, 1.86–13.32) and poor outcome at 90 days (adjusted odds ratio, 4.63; 95% CI, 1.81–11.84). A day-3 neuron-specific enolase threshold greater than 80 μg/L had a 100% specificity for prediction of both mortality (95% CI, 92–100%) and poor functional outcome (95% CI, 89–100%). In a subset of patients who underwent brain CT, neuron-specific enolase concentrations were significantly higher in patients diagnosed with stroke, as compared with those without stroke. Conclusions: In adult patients under venoarterial extracorporeal membrane oxygenation, day-3 serum neuron-specific enolase concentrations are independently associated with short-term mortality and poor functional outcomes. These findings deserve validation in a multicenter setting.
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Neurological Monitoring and Complications of Pediatric Extracorporeal Membrane Oxygenation Support. Pediatr Neurol 2020; 108:31-39. [PMID: 32299748 PMCID: PMC7698354 DOI: 10.1016/j.pediatrneurol.2020.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation is extracorporeal life support for life-threatening cardiopulmonary failure. Since its introduction, the use of extracorporeal membrane oxygenation has expanded to patients with more complex comorbidities without change in patient mortality rates. Although many patients survive, significant neurological complications like seizures, ischemic strokes, and intracranial hemorrhage can occur during extracorporeal membrane oxygenation care. The risks of these complications often add to the complexity of decision-making surrounding extracorporeal membrane oxygenation support. In this review, we discuss the pathophysiology and incidence of neurological complications in children supported on extracorporeal membrane oxygenation, factors influencing the incidence of these complications, commonly used neurological monitoring modalities, and outcomes for this complex patient population. We discuss the current literature on the use of electroencephalography for both seizure detection and monitoring of background electroencephalographic changes, in addition to the use of less commonly used imaging modalities like transcranial Doppler. We summarize the knowledge gaps and the lack of clinical consensus guidelines for managing these potentially life-changing neurological complications. Finally, we discuss future work to further understand the pathophysiology of extracorporeal membrane oxygenation-related neurological complications.
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Feiger B, Kochar A, Gounley J, Bonadonna D, Daneshmand M, Randles A. Determining the impacts of venoarterial extracorporeal membrane oxygenation on cerebral oxygenation using a one-dimensional blood flow simulator. J Biomech 2020; 104:109707. [PMID: 32220425 DOI: 10.1016/j.jbiomech.2020.109707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 02/20/2020] [Accepted: 02/23/2020] [Indexed: 01/12/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a mechanical system that provides rapid and short-term support for patients with cardiac failure. In many patients, pulmonary function is also impaired, resulting in poorly-oxygenated cardiac outflow competing against well-oxygenated VA-ECMO outflow, a condition known as North-South syndrome. North-South syndrome is a primary concern because of its potential to cause cerebral hypoxia, which has a critical influence on neurological complications often seen in this patient population. In order to reduce ischemic neurological complications, it is important to understand how clinical decisions regarding VA-ECMO parameters influence blood oxygenation. Here, we studied the impacts of flow rate and cannulation site on oxygenation using a one-dimensional (1D) model to simulate blood flow. Our model was initially tested by comparing blood flow results to those observed from experimental work in VA-ECMO patients. The 1D model was combined with a two-phase flow model to simulate oxygenation. Additionally, the influence of various other clinician-tunable parameters on oxygenation in the common carotid arteries (CCAs) were tested, including, blood viscosity, cannula position within the insertion artery, heart rate, and systemic vascular resistance (SVR), as well as geometrical changes such as arterial radius and length. Our results indicated that blood oxygenation to the brain strongly depended on the cannula insertion site and the VA-ECMO flow rate with a weaker but potentially significant dependence on arterial radius. During femoral cannulation, VA-ECMO flow rates greater than ~4.9L/min were needed to perfuse the CCAs. However, axillary and central cannulation began to perfuse the CCAs at significantly lower flow (~1L/min). These results may help explain the incidence of cerebral hypoxia in this patient population and the common need to change cannulation strategies during treatment to address this clinical problem. While this work describes patient-averaged results, determining these relationships between VA-ECMO parameters and cerebral hypoxia is an important step towards future work to develop patient-specific models that clinicians can use to improve outcomes.
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Affiliation(s)
- Bradley Feiger
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Ajar Kochar
- Department of Medicine, Duke University, Durham, NC, USA
| | - John Gounley
- Department of Biomedical Engineering, Duke University, Durham, NC, USA; Computational Sciences and Engineering Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | | | - Mani Daneshmand
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, NC, USA
| | - Amanda Randles
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.
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26
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The Role of Extracorporeal Life Support in Thoracic Surgery. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00362-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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27
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Harnisch LO, Riech S, Mueller M, Gramueller V, Quintel M, Moerer O. Longtime Neurologic Outcome of Extracorporeal Membrane Oxygenation and Non Extracorporeal Membrane Oxygenation Acute Respiratory Distress Syndrome Survivors. J Clin Med 2019; 8:jcm8071020. [PMID: 31336827 PMCID: PMC6679149 DOI: 10.3390/jcm8071020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/07/2019] [Accepted: 07/09/2019] [Indexed: 01/15/2023] Open
Abstract
Neurologic complications following acute respiratory distress syndrome (ARDS) are well described, however, information on the neurologic outcome regarding peripheral nervous system complications in critically ill ARDS patients, especially those who received extracorporeal membrane oxygenation (ECMO) are lacking. In this prospective observational study 28 ARDS patients who survived after ECMO or conventional nonECMO treatment were examined for neurological findings. Nine patients had findings related to cranial nerve innervation, which differed between ECMO and nonECMO patients (p = 0.031). ECMO patients had severely increased patella tendon reflex (PTR) reflex levels (p = 0.027 vs. p = 0.125) as well as gastrocnemius tendon reflex (GTR) (p = 0.041 right, p = 0.149 left) were affected on the right, but not on the left side presumably associated with ECMO cannulation. Paresis (14.3% of patients) was only found in the ECMO group (p = 0.067). Paresthesia was frequent (nonECMO 53.8%, ECMO 62.5%; p = 0.064), in nonECMO most frequently due to initial trauma and polyneuropathy, in the ECMO group mainly due to impairments of N. cutaneus femoris lateralis (4 vs. 0; p = 0.031). Besides well-known central neurologic complications, more subtle complications were detected by thorough clinical examination. These findings are sufficient to hamper activities of daily living and impair quality of life and psychological health and are presumably directly related to ECMO therapy.
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Affiliation(s)
- Lars-Olav Harnisch
- Department of Anesthesiology, University Medical Center Goettingen, 37075 Goettingen, Germany.
| | - Sebastian Riech
- Interdisciplinary Department of Emergency Medicine, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - Marion Mueller
- St. Josefs-Hospital Cloppenburg, Department of Anesthesia & Intensive Care, Krankenhausstr. 13, 49661 Cloppenburg, Germany
| | - Vanessa Gramueller
- Hospital Stuttgart, Department of Neurology, Kriegsbergstr. 60, 70174 Stuttgart, Germany
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Goettingen, 37075 Goettingen, Germany
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28
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Schiller RM, Tibboel D. Neurocognitive Outcome After Treatment With(out) ECMO for Neonatal Critical Respiratory or Cardiac Failure. Front Pediatr 2019; 7:494. [PMID: 31850291 PMCID: PMC6902043 DOI: 10.3389/fped.2019.00494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/13/2019] [Indexed: 01/11/2023] Open
Abstract
Over the years, it has become clear that children growing up after neonatal critical illness are at high risk of long-term neurocognitive deficits that impact their school performance and daily life activities. Although the pathophysiological mechanisms remain largely unknown, emerging evidence seems to suggest that long-term neuropsychological deficits following neonatal critical illness are not associated with the type of treatment, such as extracorporeal membrane oxygenation (ECMO), but rather with underlying disease processes. In this review, neurocognitive outcome and brain pathology following neonatal critical respiratory and cardiac illness, either treated with or without ECMO, are described and compared in order to gain insight into potential underlying pathophysiological mechanisms. Putting these findings together, it becomes apparent that both children with complex congenital heart disease and children who survived severe respiratory failure are at risk of neurocognitive deficits later in life. Neurorehabilitation strategies, such as Cogmed working-memory training, are discussed. While prevention of neurocognitive deficits altogether should be strived for in the future, this is not realistic at this moment. It is therefore of great importance that children growing up after neonatal critical illness receive long-term care that includes psychoeducation and personalized practical tools that can be used to improve their daily life activities.
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Affiliation(s)
- Raisa M Schiller
- Department of Pediatric Surgery/IC Children and Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery/IC Children and Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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