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Nagler B, Buchtele N, Hermann A, Robak O, Bojic A, Schellongowski P, Staudinger T. Comparison of Weaning Strategies in Patients Receiving Venovenous Extracorporeal Membrane Oxygenation: An Exploratory Retrospective Study. ASAIO J 2024:00002480-990000000-00478. [PMID: 38713620 DOI: 10.1097/mat.0000000000002223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024] Open
Abstract
Venovenous extracorporeal membrane oxygenation (VV ECMO) facilitates the reduction of mechanical ventilation (MV) support in acute respiratory failure. Contrary to increasing evidence regarding its initiation, the optimal timing of VV ECMO weaning in interaction with MV weaning is undetermined. In this retrospective study, 47 patients who received VV ECMO between 2013 and 2021 and survived ≥1 day after ECMO cessation were divided according to their MV status before ECMO removal: 28 patients were classified into an "ECMO weaning during assisted MV/spontaneous breathing" group and 19 into an "ECMO weaning during controlled MV" group. Extracorporeal membrane oxygenation duration was longer in the "assisted MV/spontaneous breathing" group (17 [Interquartile range (IQR) = 11-35] vs. 6 [5-11] days, p < 0.001). These patients had a longer intensive care unit (ICU) stay after ECMO start (48 [29-66] vs. 31 [15-40] days, p = 0.01). No significant differences were found for MV duration after ECMO start (30 [19-45] vs. 19 [12-30] days, p = 0.06) and further ICU survival (86% vs. 89%, p ≥ 0.9). There was a trend toward more patients with mechanical ECMO complications in the "assisted MV/spontaneous breathing" group (57% vs. 32%, p = 0.08). Thus, our results suggest a possible benefit of early ECMO weaning during controlled MV.
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Affiliation(s)
- Bernhard Nagler
- From the Department of Medicine I-Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
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2
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Busch M, Seeliger B, Fuge J, Hoeper MM, Stahl K. Fever or hypothermia following ECMO decannulation: the association of body temperature with survival. Crit Care 2024; 28:13. [PMID: 38178257 PMCID: PMC10768093 DOI: 10.1186/s13054-023-04790-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/23/2023] [Indexed: 01/06/2024] Open
Affiliation(s)
- Markus Busch
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover Medical School (MHH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover Medical School (MHH), German Center for Lung Research (DZL), Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover Medical School (MHH), German Center for Lung Research (DZL), Hannover, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Worku E, Brodie D, Shekar K. Weaning From Venovenous Extracorporeal Membrane Oxygenation-The Regensburg Way? Crit Care Med 2024; 52:147-150. [PMID: 38095522 DOI: 10.1097/ccm.0000000000006077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Elliott Worku
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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M'Pembele R, Roth S, Metzger A, Nucaro A, Stroda A, Polzin A, Hollmann MW, Lurati Buse G, Huhn R. Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Thromb J 2022; 20:42. [PMID: 35902857 PMCID: PMC9330661 DOI: 10.1186/s12959-022-00401-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The number of patients treated with extracorporeal membrane oxygenation (ECMO) devices is increasing. Anticoagulation therapy is crucial to prevent thrombosis during ECMO therapy. Predominantly, heparin has been used as primary anticoagulant but direct thrombin inhibitors (DTI) have been established as alternatives. The aim of this systematic review and meta-analysis was to evaluate clinical outcomes in patients treated with heparin compared to different DTI during ECMO. METHODS A systematic search was conducted. Full scientific articles were sought for inclusion if heparin anticoagulation was compared to DTI (argatroban/bivalirudin) in ECMO patients. Risk of bias was assessed by Newcastle Ottawa scale. Primary endpoint was in-hospital mortality. Bleeding events, thrombotic events, hours of ECMO support, days of hospital stay, percentage of time within therapeutic range and time to therapeutic range were extracted from full texts as secondary endpoints. Results were presented as Forrest-plots. GRADE was used for confidence assessment in outcomes. RESULTS Systematic search identified 4.385 records, thereof 18 retrospective studies for a total of 1942 patients, complied with the predefined eligibility criteria:15 studies investigated bivalirudin and 3 studies investigated argatroban versus heparin. Risk of bias was high for most studies. In-hospital mortality, major bleeding events and pump-related thrombosis were less frequent in DTI group as compared to heparin [mortality-OR 0.69, 95% CI 0.54-0.86; major bleeding-OR 0.48, 95% CI 0.29-0.81; pump thrombosis-OR 0.55, 95% CI 0.40-0.76]. Additionally, percentage of time within therapeutic range was higher for DTI [SMD 0.54, 95% CI 0.14-0.94]. GRADE approach revealed a very low level of certainty for each outcome. CONCLUSION In this meta-analysis, DTI and especially bivalirudin showed beneficial effects on clinical outcomes in ECMO patients as compared to heparin. However, due to the lack of randomized trials, certainty of evidence is low. TRIAL REGISTRATION This systematic review and meta-analysis was prospectively registered at PROSPERO data base (reference number CRD42021237252 ).
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Affiliation(s)
- René M'Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany.
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Aljoscha Metzger
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Anthony Nucaro
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Amsterdam, The Netherlands
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
- Department of Anesthesiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
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Castro DM, Morris I, Teijeiro-Paradis R, Fan E. Monitoring during extracorporeal membrane oxygenation. Curr Opin Crit Care 2022; 28:348-359. [PMID: 35275878 DOI: 10.1097/mcc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support. RECENT FINDINGS Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients. SUMMARY Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Idunn Morris
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Discipline of Intensive Care Medicine, Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Institute of Health Policy, Management and Evaluation
- Department of Medicine, University of Toronto, Toronto, Canada
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Fior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med 2022; 43:417-425. [PMID: 35760300 DOI: 10.1055/s-0042-1749450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.
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Affiliation(s)
- Gabriele Fior
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Zasha F Vazquez Colon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Florida, Shands Children's Hospital, Gainesville, Florida
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, Shands Children's Hospital, Gainesville, University of Florida, Gainesville, Florida
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital and The Wesley Hospital, Uniting Care Hospitals, Brisbane, QLD, Australia
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8
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Association of Respiratory Parameters at Venovenous Extracorporeal Membrane Oxygenation Liberation With Duration of Mechanical Ventilation and ICU Length of Stay: A Prospective Cohort Study. Crit Care Explor 2022; 4:e0689. [PMID: 35517643 PMCID: PMC9067359 DOI: 10.1097/cce.0000000000000689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Yu TZ, Tatum RT, Saxena A, Ahmad D, Yost CC, Maynes EJ, O'Malley TJ, Massey HT, Swol J, Whitson BA, Tchantchaleishvili V. Utilization and outcomes of extracorporeal CO 2 removal (ECCO 2 R): Systematic review and meta-analysis of arterio-venous and veno-venous ECCO 2 R approaches. Artif Organs 2021; 46:763-774. [PMID: 34897748 DOI: 10.1111/aor.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/25/2021] [Accepted: 11/09/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Extracorporeal carbon dioxide removal (ECCO2 R) provides respiratory support to patients suffering from hypercapnic respiratory failure by utilizing an extracorporeal shunt and gas exchange membrane to remove CO2 from either the venous (VV-ECCO2 R) or arterial (AV-ECCO2 R) system before return into the venous site. AV-ECCO2 R relies on the patient's native cardiac function to generate pressures needed to deliver blood through the extracorporeal circuit. VV-ECCO2 R utilizes a mechanical pump and can be used to treat patients with inadequate native cardiac function. We sought to evaluate the existing evidence comparing the subgroups of patients supported on VV and AV-ECCO2 R devices. METHODS A literature search was performed to identify all relevant studies published between 2000 and 2019. Demographic information, medical indications, perioperative variables, and clinical outcomes were extracted for systematic review and meta-analysis. RESULTS Twenty-five studies including 826 patients were reviewed. 60% of patients (497/826) were supported on VV-ECCO2 R. The most frequent indications were acute respiratory distress syndrome (ARDS) [69%, (95%CI: 53%-82%)] and chronic obstructive pulmonary disease (COPD) [49%, (95%CI: 37%-60%)]. ICU length of stay was significantly shorter in patients supported on VV-ECCO2 R compared to AV-ECCO2 R [15 (95%CI: 7-23) vs. 42 (95%CI: 17-67) days, p = 0.05]. In-hospital mortality was not significantly different [27% (95%CI: 18%-38%) vs. 36% (95%CI: 24%-51%), p = 0.26]. CONCLUSION Both VV and AV-ECCO2 R provided clinically meaningful CO2 removal with comparable mortality.
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Affiliation(s)
- Tiffany Z Yu
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert T Tatum
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Abhiraj Saxena
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Danial Ahmad
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Colin C Yost
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth J Maynes
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas J O'Malley
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard T Massey
- Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Gannon WD, Stokes JW, Bloom S, Sherrill W, Bacchetta M, Rice TW, Semler MW, Casey JD. Safety and Feasibility of a Protocolized Daily Assessment of Readiness for Liberation From Venovenous Extracorporeal Membrane Oxygenation. Chest 2021; 160:1693-1703. [PMID: 34166644 PMCID: PMC8727855 DOI: 10.1016/j.chest.2021.05.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Decannulation from venovenous extracorporeal membrane oxygenation (ECMO) at the earliest and safest possible time may improve outcomes and reduce cost. Yet, no prospective studies have compared weaning strategies for liberation from ECMO. RESEARCH QUESTION Is a protocolized daily assessment of readiness to liberate from venovenous ECMO safe and feasible? STUDY DESIGN AND METHODS We conducted a prospective, single-arm safety and feasibility study of a protocol for daily assessment of readiness to liberate from venovenous ECMO among consecutive adult patients receiving venovenous ECMO across four ICUs at a single center between June 20, 2020, and November 24, 2020. The ECMO-free protocol included three phases: (1) the safety screening, (2) non-ECMO Fio2 titration, and (3) the ECMO-free trial. Enrollment, interventions, and data collection were performed prospectively by trained study staff. RESULTS Twenty-six patients received the ECMO-free protocol on 385 patient-days. The safety screening was passed during a total of 59 ECMO-free daily assessments (15.3%) among 20 patients. Every passed safety screening proceeded to an ECMO-free trial. Twenty-eight passed ECMO-free trials (47.5%) occurred among 16 patients (61.5%). No missed safety screenings, protocol deviations, or adverse events occurred. Of the 16 patients who passed an ECMO-free trial, 14 patients (87.5%) were decannulated. Among decannulated patients, 12 patients (85.7%) were decannulated on the same day as a passed ECMO-free trial, 6 patients (42.9%) were decannulated on the first day that they passed an ECMO-free trial, and 6 patients (42.9%) passed an ECMO-free trial at least twice consecutively before decannulation. The median time from first passed ECMO-free trial to decannulation was 2 days (interquartile range, 0-3 days). INTERPRETATION The ECMO-free protocol is feasible and may identify patients for decannulation earlier than gradual approaches to weaning.
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Affiliation(s)
- Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Bloom
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wren Sherrill
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew W Semler
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D Casey
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Potere B, Boulos R, Awad H, Taylor A, Kneuertz PJ, Cline M, Meyers L, Essandoh M, Henn M, Dalton R. The Role of Extracorporeal Membrane Oxygenation in the Anesthetic Management of Superior Vena Cava Syndrome: Is it Time to Use a Scoring System? J Cardiothorac Vasc Anesth 2021; 36:1777-1787. [PMID: 34531109 DOI: 10.1053/j.jvca.2021.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Bethany Potere
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Racha Boulos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Ashley Taylor
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Peter J Kneuertz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Cline
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lori Meyers
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Matthew Henn
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ryan Dalton
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Cumulative Fluid Balance during Extracorporeal Membrane Oxygenation and Mortality in Patients with Acute Respiratory Distress Syndrome. MEMBRANES 2021; 11:membranes11080567. [PMID: 34436331 PMCID: PMC8402131 DOI: 10.3390/membranes11080567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in cases of severe acute respiratory distress syndrome (ARDS) with profound hypoxemia. However, the need for high-volume fluid resuscitation and blood transfusions after ECMO initiation introduces a risk of fluid overload. Positive fluid balance is associated with mortality in critically ill patients, and conservative fluid management for ARDS patients has been shown to shorten both the duration of mechanical ventilation and time spent in intensive care, albeit without a significant effect on survival. Nonetheless, few studies have addressed the influence of fluid balance on clinical outcomes in severe ARDS patients undergoing ECMO. In the current retrospective study, we examined the impact of cumulative fluid balance (CFB) on hospital mortality in 152 cases of severe ARDS treated using ECMO. Overall hospital mortality was 53.3%, and we observed a stepwise positive correlation between CFB and the risk of death. Cox regression models revealed that CFB during the first 3 days of ECMO was independently associated with higher hospital mortality (adjusted hazard ratio 1.110 [95% CI 1.027–1.201]; p = 0.009). Our findings indicate the benefits of a conservative treatment approach to avoid fluid overload during the early phase of ECMO when dealing with severe ARDS patients.
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Getting SILI between Two Extracorporeal Membrane Oxygenation Runs. Ann Am Thorac Soc 2021; 18:167-171. [PMID: 33385223 DOI: 10.1513/annalsats.202007-814cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Consales G, Zamidei L, Turani F, Atzeni D, Isoni P, Boscolo G, Saggioro D, Resta MV, Ronco C. Combined Renal-Pulmonary Extracorporeal Support with Low Blood Flow Techniques: A Retrospective Observational Study (CICERO Study). Blood Purif 2021; 51:299-308. [PMID: 34237722 DOI: 10.1159/000517280] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 05/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critically ill patients with acute respiratory failure frequently present concomitant lung and kidney injury, within a multiorgan failure condition due to local and systemic mediators. To face this issue, extracorporeal carbon dioxide removal (ECCO2R) systems have been integrated into continuous renal replacement therapy (CRRT) platforms to provide a combined organ support, with efficient clearance of CO2 with very low extracorporeal blood flows (<400 mL/min). OBJECTIVES To evaluate efficacy and safety of combined ECCO2R-CRRT support with PrismaLung®-Prismaflex® in patients affected by hypercapnic respiratory acidosis associated with AKI in a second level intensive care unit. METHODS We carried out a retrospective observational study enrolling patients submitted to PrismaLung®-Prismaflex® due to mild to moderate acute respiratory distress syndrome (ARDS) or acute exacerbation of chronic obstructive pulmonary disease (aeCOPD). The primary endpoints were the shift to protective ventilation and extubation of mechanically ventilated patients and the shift to invasive mechanical ventilation of patients receiving noninvasive ventilation (NIV). Clinical-laboratoristic data and operational characteristics of ECCO2R-CRRT were recorded. RESULTS Overall, 12/17 patients on mechanical ventilation shifted to protective ventilation, CO2 clearance was satisfactorily maintained during the whole observational period, and pH was rapidly corrected. Treatment prevented NIV failure in 4 out of 5 patients. No treatment-related complications were recorded. CONCLUSION ECCO2R-CRRT was effective and safe in patients with aeCOPD and ARDS associated with AKI.
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Affiliation(s)
- Guglielmo Consales
- Emergency and Critical Care Department, S. Stefano Hospital, Prato, Italy
| | - Lucia Zamidei
- Emergency and Critical Care Department, S. Stefano Hospital, Prato, Italy
| | - Franco Turani
- Anaesthesia and Critical Care Department, Aurelia and European Hospital, Rome, Italy
| | - Diego Atzeni
- Cardioanaesthesia and Cardiosurgical Intensive Care Unit, Cardiovascular Department, San Michele Hospital, AO Brotzu, Cagliari, Italy
| | - Paolo Isoni
- Anaesthesia and Critical Care Unit, PO Santissima Trinità, ASSL Cagliari, Cagliari, Italy
| | - Gloria Boscolo
- Anaesthesia and Critical Care Department, dell'Angelo Hospital, Venice, Italy
| | - Debora Saggioro
- Anaesthesia and Critical Care Department, dell'Angelo Hospital, Venice, Italy
| | - Marco Vittorio Resta
- Anaesthesia and Critical Care Department, IRCCS San Donato Milanese Policlinic, San Donato Milanese, Milan, Italy
| | - Claudio Ronco
- DIMED, San Bortolo Hospital, University of Padova and International Renal Research Institute (IRRIV), Vicenza, Italy
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15
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Al-Fares AA, Ferguson ND, Ma J, Cypel M, Keshavjee S, Fan E, Del Sorbo L. Achieving Safe Liberation During Weaning from VV-ECMO in Patients with Severe ARDS: The role of Tidal Volume and Inspiratory Effort. Chest 2021; 160:1704-1713. [PMID: 34166645 DOI: 10.1016/j.chest.2021.05.068] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/16/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Weaning from venovenous extracorporeal membrane oxygenation (VV-ECMO) is not well studied. VV-ECMO can be discontinued when patients tolerate non-injurious mechanical ventilation (MV) during a sweep gas off trial (SGOT). However, predictors of safe liberation are unknown. RESEARCH QUESTION Can safe liberation from VV-ECMO be predicted at the bedside? STUDY DESIGN AND METHODS We conducted 2 observational studies of adults weaned from VV-ECMO for severe ARDS at Toronto General Hospital. We analyzed MV settings, respiratory mechanics and clinical variables to predict safe liberation from VV-ECMO, defined a priori as avoidance of ECMO recannulation, increase MV support, need for rescue therapy or hemodynamic instability developed within 48 hours after decannulation. RESULTS During both studies, 83 patients were weaned from VV-ECMO, of whom 21 (25%) did not meet criteria for safe liberation. In the retrospective study, higher tidal volume per predicted body weight (VTpbw, OR 1.58, 95%CI 1.05-2.40, P=0.03) and heart rate (HR, OR 1.07, 95%CI 1.01-1.13, P=0.02) at the end of SGOT were significantly associated with increased odds of unsafe liberation when adjusted for age (OR 1.02, 95%CI 0.95-1.09, P=0.63) and SOFA (OR 1.16, 95%CI 0.86-1.56, P=0.34). Change in ventilatory ratio (VR) had an imprecise association (OR 2.71, 95%CI 0.93-7.92, P=0.06) with unsafe liberation when adjusted for age (OR 1.03, 95%CI 0.96-1.10, P=0.42), SOFA (OR 1.11, 95%CI 0.81-1.51, P=0.52) and heart rate (OR 1.07, 95%CI 1.01-1.13, P=0.02). In the prospective study, patients who had unsafe liberation from VV-ECMO also had significantly higher inspiratory efforts (esophageal pressure swings 9 [7-13] vs 18 [7-25] cmH2O, p=0.03), and worse outcomes (longer MV duration, ICU and hospital length of stay). INTERPRETATION Patients with higher tidal volume, heart rate, ventilatory ratio, and esophageal pressures swings during SGOT were less likely to achieve safe liberation from VV-ECMO.
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Affiliation(s)
- Abdulrahman A Al-Fares
- Deapartment of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait(,); Kuwait Extracorporeal life support program, Al-Amiri Hospital Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait; Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Extracorporeal Life Support Program, Toronto General Hospital, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Extracorporeal Life Support Program, Toronto General Hospital, Canada; Institute of Health Management, Policy and Evaluation, University of Toronto; Toronto General Hospital Research Institute, Toronto, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Extracorporeal Life Support Program, Toronto General Hospital, Canada; Toronto General Hospital Research Institute, Toronto, Canada
| | - Shaf Keshavjee
- Extracorporeal Life Support Program, Toronto General Hospital, Canada; Toronto General Hospital Research Institute, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Extracorporeal Life Support Program, Toronto General Hospital, Canada; Institute of Health Management, Policy and Evaluation, University of Toronto; Toronto General Hospital Research Institute, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Extracorporeal Life Support Program, Toronto General Hospital, Canada.
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16
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Belliato M, Cremascoli L, Epis F, Ferrari F, Quattrone MG, Malfertheiner MV, Broman LM, Aliberti A, Taccone FS, Iotti GA, Lorusso R. Carbon Dioxide Elimination During Veno-Venous Extracorporeal Membrane Oxygenation Weaning: A Pilot Study. ASAIO J 2021; 67:700-708. [PMID: 33074866 DOI: 10.1097/mat.0000000000001282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO2) removal (V'CO2TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V'CO2NL ratio (V'CO2NL/V'CO2TOT) value was calculated based on the distribution of CO2 between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V'CO2NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V'CO2NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.
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Affiliation(s)
- Mirko Belliato
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fiorenza Ferrari
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria G Quattrone
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Maximilian V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Medical Center Regensburg, Regensburg, Germany
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Aliberti
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Bruxelles (CUB) Erasme, Brussels, Belgium
| | - Giorgio A Iotti
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
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17
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Ali Usman A, Gutsche J. Essential Topics in the Management of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Acute Respiratory Distress Syndrome. J Cardiothorac Vasc Anesth 2021; 35:2552-2555. [PMID: 34088550 PMCID: PMC8105130 DOI: 10.1053/j.jvca.2021.04.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 04/28/2021] [Indexed: 01/08/2023]
Affiliation(s)
- Asad Ali Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
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18
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Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions. MEMBRANES 2021; 11:membranes11030172. [PMID: 33670987 PMCID: PMC7997339 DOI: 10.3390/membranes11030172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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19
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Extracorporeal support to achieve lung-protective and diaphragm-protective ventilation. Curr Opin Crit Care 2020; 26:66-72. [PMID: 31876625 DOI: 10.1097/mcc.0000000000000686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring. RECENT FINDINGS A recent randomized trial comparing the efficacy of extracorporeal support as a rescue therapy to conventional protective mechanical ventilation was stopped for futility but post hoc analyses suggested that extracorporeal support is beneficial for patients with very severe acute respiratory distress syndrome. However, the optimal ventilation settings during extracorporeal support are still debated. It is conceivable that they should enable the highest amount of CO2 removal with lowest mechanical power.Extracorporeal CO2 removal can minimize acidosis and enable the use of ultra-protective lung ventilation strategies when hypoxemia is not a major issue. Moreover, it can protect lung and diaphragm function during assisted ventilation through control of the respiratory effort.Lung mechanics, gas exchange, diaphragm electrical activity, ultrasound, electrical impedance tomography could be integrated into clinical management to define lung and diaphragm protection and guide personalized ventilation settings. SUMMARY Technological improvement and the latest evidence indicate that extracorporeal support may be an effective tool for lung and diaphragm protection.
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20
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Toward Respiratory Support of Critically Ill COVID-19 Patients Using Repurposed Kidney Hollow Fiber Membrane Dialysers to Oxygenate the Blood. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:8862645. [PMID: 33425312 PMCID: PMC7780225 DOI: 10.1155/2020/8862645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/22/2020] [Indexed: 11/17/2022]
Abstract
The COVID-19 pandemic has highlighted resource constraints in respiratory support. The oxygen transfer characteristics of a specific hollow fiber membrane dialyser was investigated with a view to repurposing the device as a low-cost, readily available blood oxygenator. Oxygen transfer in a low-flux hollow fiber dialyser with a polysulfone membrane was studied by passing first water and then blood through the dialyser in countercurrent to high-purity oxygen. Oxygen transfer rates of about 15% of the nominal 250 ml (STP)/min of a typical adult oxygen consumption rate were achieved for blood flow rates of 500 ml/min. Using two such dialysis devices in parallel could provide up to 30% of the nominal oxygen consumption. Specific hollow fiber dialysis devices operating with suitable pumps in a veno-venous access configuration could provide a cost-effective and readily available supplementation of respiratory support in the face of severe resource constraints.
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21
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Combes A, Schmidt M, Hodgson CL, Fan E, Ferguson ND, Fraser JF, Jaber S, Pesenti A, Ranieri M, Rowan K, Shekar K, Slutsky AS, Brodie D. Extracorporeal life support for adults with acute respiratory distress syndrome. Intensive Care Med 2020; 46:2464-2476. [PMID: 33140180 PMCID: PMC7605473 DOI: 10.1007/s00134-020-06290-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/10/2020] [Indexed: 12/28/2022]
Abstract
Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCO2R) uses lower blood flow rates through smaller cannulae and provides substantial CO2 elimination (~ 20–70% of total CO2 production), albeit with marginal improvement in oxygenation. The rationale for using ECCO2R in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCO2R for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France. .,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France.
| | - Matthieu Schmidt
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France.,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care-Research Centre, Monash University, Melbourne, Australia
| | - Eddy Fan
- Interdepartmenal Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, Northside Medical School, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
| | - Samir Jaber
- Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), From the PhyMedExp, University of Montpellier, Centre Hospitalier Universitaire (CHU) Montpellier, Montpellier, France.,Département d'Anesthésie-Réanimation, Hôpital Saint-Eloi, Montpellier Cedex, France
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Marco Ranieri
- Intensive Care Unit, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Kiran Shekar
- Adult Intensive Care Services, Critical Care Research Group, the Prince Charles Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, University of Queensland, Brisbane, QLD, Australia
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, USA.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York, USA
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22
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Shekar K, Buscher H, Brodie D. Protocol-driven daily optimisation of venovenous extracorporeal membrane oxygenation blood flows: an alternate paradigm? J Thorac Dis 2020; 12:6854-6860. [PMID: 33282387 PMCID: PMC7711363 DOI: 10.21037/jtd-20-1515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venovenous extracorporeal membrane oxygenation (VV ECMO) is now an established modality of support for patients with the who are failing evidence-based conventional therapies. Minimising ventilator-induced lung injury is the guiding principle behind patient management with VV ECMO. Patients with acute respiratory distress syndrome (ARDS) supported with VV ECMO are liberated from ECMO at a stage when native lungs have recovered sufficiently to support physiologic demands and the risks of iatrogenic lung injuries after discontinuation of ECMO are perceived to be small. However, native lung recovery is a dynamic process and patients rely on varying degrees of contributions from both native lungs and ECMO for gas exchange support. Patients often demonstrate near total ECMO dependence for oxygenation and decarboxylation early in the course of the illness and this may necessitate higher ECMO blood flow rates (EBFRs). Although, reliance on high EBFR for oxygenation support may remain variable over the course of ECMO, blood flow requirements typically diminish over time as native lungs start to recover. Currently, protocol-driven modulation of the EBFR based on changing physiologic needs is not common practice and consequently patients may remain on higher than physiologically necessary EBFR. This exposes the patient to potential risks because maintaining higher blood flows often requires a less restrictive fluid balance and deeper sedation. Both may be harmful in the setting of recovery from ARDS. In this article, we propose a strategy that involves daily assessments of native lung function and a protocol-driven daily optimisation of EBFR. This is followed by optimisation of sweep gas flow rate (SGFR) and the fraction of delivered oxygen in the sweep gas (FdO2). This staged approach to weaning VV ECMO allows us to fully utilise the “decoupling” of oxygenation and decarboxylation that is possible only during extracorporeal support. This approach may benefit patients by allowing for greater fluid restriction, more aggressive fluid removal, expedited weaning of sedation and neuromuscular blocking agents (NMBAs), and early physical rehabilitation. Ultimately, prospective studies are needed to evaluate optimal VV ECMO weaning practices
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Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane and Bond University, Gold Coast, Queensland, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine and Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Daniel Brodie
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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23
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Ntoumenopoulos G, Buscher H, Scott S. Lung ultrasound score as an indicator of dynamic lung compliance during veno-venous extra-corporeal membrane oxygenation. Int J Artif Organs 2020; 44:194-198. [PMID: 32779510 DOI: 10.1177/0391398820948870] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Decisions on weaning from veno-venous extra-corporeal membrane oxygenation (VV-ECMO) requires the ability to maintain adequate gas exchange and work of breathing with reductions in ECMO pump flow and fresh gas flow. Testing of the readiness to wean the patient from ECMO however may vary dependent upon local protocols and clinical judgment. This study sought to validate the use of the LUS-score during VV-ECMO against the changes in chest x-ray infiltrates, dynamic lung compliance (CLdyn) and VV-ECMO settings (as standard measures of native lung function and the level of ECMO support) during the ECMO cycle. This prospective cohort study of 10 patients on VV-ECMO compared the LUS score (range 0-36) within 48-h, day 5 and day 10 of commencement of ECMO (or on the day of ECMO decannulation) to dynamic lung compliance, Murray Lung Injury Score and ECMO settings. Seven Male and three Female patients were included (average age 37 years (SD 14.8) and weight 71 Kg (SD 16.9). Median (IQR) duration of ECMO, ICU and hospital length of stay was 7.5 days (5.2-19.0), 12.5 days (8.5-22.7), 19.0 days (12.1- 36.1), respectively. There was a strong negative association between LUS-score and dynamic lung compliance (rs(33) = -0.66, p < .001) providing some validation on the use of the LUS score as a potential surrogate measure of lung aeration and lung mechanics during VV-ECMO weaning.
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Affiliation(s)
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Australia.,Centre of Applied Medical Research, University of New South Wales, Australia
| | - Sean Scott
- Department of Intensive Care Medicine, St Vincent's Hospital, Australia.,The University of Notre Dame, Australia
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24
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Holzgraefe B, Larsson A, Eksborg S, Kalzén H. Does extracorporeal membrane oxygenation attenuate hypoxic pulmonary vasoconstriction in a porcine model of global alveolar hypoxia? Acta Anaesthesiol Scand 2020; 64:992-1001. [PMID: 32236954 DOI: 10.1111/aas.13588] [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: 10/27/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND During severe respiratory failure, hypoxic pulmonary vasoconstriction (HPV) is partly suppressed, but may still play a role in increasing pulmonary vascular resistance (PVR). Experimental studies suggest that the degree of HPV during severe respiratory failure is dependent on pulmonary oxygen tension (PvO2 ). Therefore, it has been suggested that increasing PvO2 by veno-venous extracorporeal membrane oxygenation (V-V ECMO) would adequately reduce PVR in V-V ECMO patients. OBJECTIVE Whether increased PvO2 by V-V ECMO decreases PVR in global alveolar hypoxia. METHODS Nine landrace pigs were ventilated with a mixture of oxygen and nitrogen. After 15 minutes of stable ventilation and hemodynamics, the animals were cannulated for V-V ECMO. Starting with alveolar normoxia, the fraction of inspiratory oxygen (FI O2 ) was stepwise reduced to establish different degrees of alveolar hypoxia. PvO2 was increased by V-V ECMO. RESULTS V-V ECMO decreased PVR (from 5.5 [4.5-7.1] to 3.4 [2.6-3.9] mm Hg L-1 min, P = .006) (median (interquartile range),) during ventilation with FI O2 of 0.15. At lower FI O2 , PVR increased; at FI O2 0.10 to 4.9 [4.2-7.0], P = .036, at FI O2 0.05 to 6.0 [4.3-8.6], P = .002, and at FI O2 0 to 5.4 [3.5 - 7.0] mm Hg L-1 min, P = .05. CONCLUSIONS The effect of increased PvO2 by V-V ECMO on PVR depended highly on the degree of alveolar hypoxia. Our results partly explain why V-V ECMO does not always reduce right ventricular afterload at severe alveolar hypoxia.
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Affiliation(s)
- Bernhard Holzgraefe
- Hedenstierna Laboratory Department of Surgical Sciences Uppsala University Uppsala Sweden
- Department of Anaesthesia Surgical Services and Intensive Care Medicine Arvika Community Hospital Arvika Sweden
| | - Anders Larsson
- Hedenstierna Laboratory Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Staffan Eksborg
- Department of Pediatric Anesthesia Intensive Care and ECMO services Astrid Lindgren Children's Hospital, Karolinska Institutet Karolinska University Hospital Solna Stockholm Sweden
- Childhood Cancer Research Unit Q6:05 Department of Women's and Children's Health Karolinska Institutet Astrid Lindgren Children's Hospital Karolinska University Hospital Solna Stockholm Sweden
| | - Håkan Kalzén
- Department of Pediatric Anesthesia Intensive Care and ECMO services Astrid Lindgren Children's Hospital, Karolinska Institutet Karolinska University Hospital Solna Stockholm Sweden
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25
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Less Data for More Outcome. Crit Care Med 2020; 47:1662-1664. [PMID: 31609264 DOI: 10.1097/ccm.0000000000003989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Steuer NB, Hugenroth K, Beck T, Spillner J, Kopp R, Reinartz S, Schmitz-Rode T, Steinseifer U, Wagner G, Arens J. Long-Term Venovenous Connection for Extracorporeal Carbon Dioxide Removal (ECCO 2R)-Numerical Investigation of the Connection to the Common Iliac Veins. Cardiovasc Eng Technol 2020; 11:362-380. [PMID: 32405926 PMCID: PMC7385029 DOI: 10.1007/s13239-020-00466-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/02/2020] [Indexed: 02/06/2023]
Abstract
Purpose Currently used cannulae for extracorporeal carbon dioxide removal (ECCO2R) are associated with complications such as thrombosis and distal limb ischemia, especially for long-term use. We hypothesize that the risk of these complications is reducible by attaching hemodynamically optimized grafts to the patient’s vessels. In this study, as a first step towards a long-term stable ECCO2R connection, we investigated the feasibility of a venovenous connection to the common iliac veins. To ensure its applicability, the drainage of reinfused blood (recirculation) and high wall shear stress (WSS) must be avoided. Methods A reference model was selected for computational fluid dynamics, on the basis of the analysis of imaging data. Initially, a sensitivity analysis regarding recirculation was conducted using as variables: blood flow, the distance of drainage and return to the iliocaval junction, as well as the diameter and position of the grafts. Subsequently, the connection was optimized regarding recirculation and the WSS was evaluated. We validated the simulations in a silicone model traversed by dyed fluid. Results The simulations were in good agreement with the validation measurements (mean deviation 1.64%). The recirculation ranged from 32.1 to 0%. The maximum WSS did not exceed 5.57 Pa. The position and diameter of the return graft show the highest influence on recirculation. A correlation was ascertained between recirculation and WSS. Overall, an inflow jet directed at a vessel wall entails not only high WSS, but also a flow separation and thereby an increased recirculation. Therefore, return grafts aligned to the vena cava are crucial. Conclusion In conclusion, a connection without recirculation could be feasible and therefore provides a promising option for a long-term ECCO2R connection.
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Affiliation(s)
- N B Steuer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - K Hugenroth
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - T Beck
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - J Spillner
- Clinic for Cardiothoracic Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - R Kopp
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - S Reinartz
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - T Schmitz-Rode
- Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - U Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - G Wagner
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - J Arens
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany.,Chair in Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, Enschede, The Netherlands
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Spinelli E, Grieco DL, Mauri T. A personalized approach to the acute respiratory distress syndrome: recent advances and future challenges. J Thorac Dis 2019; 11:5619-5625. [PMID: 32030284 DOI: 10.21037/jtd.2019.11.61] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, IRCCS Foundation "Ca' Granda" "Maggiore Policlinico" Hospital, Milan, Italy
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS Foundation "Ca' Granda" "Maggiore Policlinico" Hospital, Milan, Italy
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Vasques F, Romitti F, Gattinoni L, Camporota L. How I wean patients from veno-venous extra-corporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:316. [PMID: 31533848 PMCID: PMC6749626 DOI: 10.1186/s13054-019-2592-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/29/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Francesco Vasques
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, King's Health Partners, King's College London, 6th Floor East Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Federica Romitti
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, King's Health Partners, King's College London, 6th Floor East Wing, Westminster Bridge Road, London, SE1 7EH, UK.
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Blandino Ortiz A, Cabestrero Alonso D, De Pablo Sánchez R. Veno-venous ECMO indications: more than respiratory support. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:275. [PMID: 31391059 PMCID: PMC6686485 DOI: 10.1186/s13054-019-2555-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/25/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Aaron Blandino Ortiz
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Ctra. Colmenar Viejo, KM 9100, 28034, Madrid, Spain.
| | - David Cabestrero Alonso
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Ctra. Colmenar Viejo, KM 9100, 28034, Madrid, Spain
| | - Raúl De Pablo Sánchez
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Ctra. Colmenar Viejo, KM 9100, 28034, Madrid, Spain
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