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Ren X, Ai Y, Zhang L, Zhao C, Li L, Ma X. Sedation and analgesia requirements during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome patients. Perfusion 2023; 38:313-319. [PMID: 34743615 DOI: 10.1177/02676591211052160] [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: 11/17/2022]
Abstract
INTRODUCTION The purpose of this study is to describe sedation and analgesia management, and identify the factors associated with increased demand for medication in acute respiratory distress syndrome (ARDS) patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). METHODS This retrospective, single-center study included consecutive adult ARDS patients who received VV-ECMO for at least 24 hours from January 2018 to December 2020 in a comprehensive intensive care unit. The electronic medical records were retrospectively reviewed to collect data. RESULTS Forty-two adult patients meeting the inclusion criteria were included in the study. Midazolam, sufentanil, and remifentanil were main sedatives and analgesics used in the patient population. The morphine equivalents, representative of the demand for opioids, was 512.9 (IQR, 294.5, 798.2) mg/day. The midazolam equivalents, representative of benzodiazepine requirement, was 279.6 (IQR, 208.8, 384.5) mg/day. The levels of serum creatinine, total bilirubin, lactic acid, SOFA score, and APACHE Ⅱ score at cannulation were found to be associated with opiate or benzodiazepine requirements. Multiple linear regression analysis revealed a linear correlation between midazolam equivalents and morphine equivalents (p < 0.001). In addition, there was a negative linear correlation between Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score and midazolam equivalents (p = 0.024). CONCLUSIONS The sedation and analgesia requirements of ARDS patients receiving VV-ECMO often increase simultaneously. More large-scale studies are needed to confirm the risk factors for increased sedation and analgesia needs in patients supported on VV-ECMO.
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Affiliation(s)
- Xingshu Ren
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Chunguang Zhao
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Li Li
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
| | - Xinhua Ma
- Department of Critical Care Medicine, Xiangya Hospital of Central South University, Changsha, China
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De Mol AC, Van Heijst AF, Van Der Staak FH, Liem KD. Disturbed Cerebral Circulation during Opening of the Venoarterial Bypass Bridge in Extracorporeal Membrane Oxygenation. Int J Artif Organs 2018; 31:266-71. [DOI: 10.1177/039139880803100311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose To describe the effects on cerebral blood flow velocity (CBFV) of intermittent opening of the venoarterial bridge (VA bridge) during venoarterial extracorporeal membrane oxygenation (VA-ECMO). Study design Prospective study in 22 newborns during VA-ECMO. CBFV was measured in the perical-losal artery by Doppler ultrasound. Changes in peak systolic flow velocity (PSV), end diastolic flow velocity (EDV) and time-averaged mean flow velocity (TAM) on day 1, 2, 3, and 5 and at low ECMO flow (50–150 ml/min) were analyzed (mean percentage±standard deviation (t-tests, p<0.05)). Changes >25% were considered relevant. The relationship between changes in CBFV and ECMO flow rate (Pearson correlation, p<0.01) was studied. Results Opening of the VA bridge resulted in statistically significant and relevant decreases in PSV (35 ± 18%), EDV (93 ± 15%) and TAM (68 ± 13%), persisting during the consecutive days of treatment. Smaller changes in CBFV at low ECMO flow were statistically significant and mostly relevant: PSV (15 ± 7%), EDV (76 ± 21%) and TAM (40 ± 12%). Changes in CBFV were positively correlated to the ECMO flow. Conclusion: Use of the VA bridge results in significant and relevant ECMO flow-dependent changes in CBFV, persisting during the treatment. The VA bridge should be used in such a way as to allow regular unclamping to be omitted.
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Affiliation(s)
- A. C. De Mol
- Department of Pediatrics, Neonatology, Radboud University Nijmegen Medical Center, Nijmegen - The Netherlands
| | - A. F. Van Heijst
- Department of Pediatrics, Neonatology, Radboud University Nijmegen Medical Center, Nijmegen - The Netherlands
| | - F. H. Van Der Staak
- Department of Pediatric Surgery, Radboud University Nijmegen Medical Center - Nijmegen - The Netherlands
| | - K. D. Liem
- Department of Pediatrics, Neonatology, Radboud University Nijmegen Medical Center, Nijmegen - The Netherlands
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Lahmer T, Mayr U, Rasch S, Batres Baires G, Schmid RM, Huber W. In-parallel connected intermittent hemodialysis through ECMO does not affect hemodynamic parameters derived from transpulmonary thermodilution. Perfusion 2017; 32:702-705. [DOI: 10.1177/0267659117707816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: We report a case of renal replacement therapy (RRT) during extracorporeal membrane oxygenation (ECMO) via a single venous access and analyze the feasibility of transpulmonary thermodilution (TPTD) for hemodynamic monitoring. Case report: ECMO and RRT connected into the ECMO-extracorporeal circuit were performed via a single venous access because of multiple venous thromboses. An indicator for TPTD and pulse contour analysis (PCA) was applied into the central venous catheter (CVC) placed in the right vena jugularis. TPTD and PCA demonstrated comparable cardiac index. Discussion: Congruent data for TPTD and PCA could be observed during TPTD and PCA measurements before ECMO, after ECMO and during ECMO and RRT. This might be explained by high blood flow having the lowest impact on TPTD by venous drainage in the femoral vein/distal vena cava and the TPTD indicator injection using the jugular CVC, as reported in our case. Conclusion: Hemodynamic monitoring using TPTD and PCA during ECMO/RRT is feasible and provides reliable results.
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Affiliation(s)
- Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Ulrich Mayr
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Sebastian Rasch
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Gonzalo Batres Baires
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
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Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an effective therapy for patients with reversible cardiac and/or respiratory failure. Acute kidney injury (AKI) often occurs in patients supported with ECMO; it frequently evolves into chronic kidney damage or end-stage renal disease and is associated with a reported 4-fold increase in mortality rate. Although AKI is generally due to the hemodynamic alterations associated with the baseline disease, ECMO itself may contribute to maintaining kidney dysfunction through several mechanisms. SUMMARY AKI may be related to conditions derived from or associated with extracorporeal therapy, leading to a reduction in renal oxygen delivery and/or to inflammatory damage. In particular, during pathological conditions requiring ECMO, the biological defense mechanisms maintaining central perfusion by a reduction of perfusion to peripheral organs (such as the kidney) have been identified as pretreatment and patient-related risk factors for AKI. Hormonal pathways are also impaired in patients supported with ECMO, leading to failures in mechanisms of renal homeostasis and worsening fluid overload. Finally, inflammatory damage, due to the primary disease, heart and lung crosstalk with the kidney or associated with extracorporeal therapy itself, may further increase the susceptibility to AKI. Renal replacement therapy can be integrated into the main extracorporeal circuit during ECMO to provide for optimal fluid management and removal of inflammatory mediators. KEY MESSAGES AKI is frequently observed in patients supported with ECMO. The pathophysiology of the associated AKI is chiefly related to a reduction in renal oxygen delivery and/or to inflammatory damage. Risk factors for AKI are associated with a patient's underlying disease and ECMO-related conditions.
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Affiliation(s)
- Gianluca Villa
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Nevin Katz
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md., USA
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
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Askenazi DJ, Selewski DT, Paden ML, Cooper DS, Bridges BC, Zappitelli M, Fleming GM. Renal replacement therapy in critically ill patients receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol 2012; 7:1328-36. [PMID: 22498496 DOI: 10.2215/cjn.12731211] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure used in neonates, children, and adults with severe, reversible, cardiopulmonary failure. On the basis of single-center studies, the incidence of AKI occurs in 70%-85% of ECMO patients. Those with AKI and those who require renal replacement therapy (RRT) are at high risk for mortality, independent of potentially confounding variables. Fluid overload is common in ECMO patients, and is one of the main indications for RRT. RRT to maintain fluid balance and metabolic control is common in some but not all centers. RRT on ECMO can be performed via an in-line hemofilter or by incorporating a standard continuous renal replacement machine into the ECMO circuit. Both of these methods require specific technical considerations to provide safe and effective RRT. This review summarizes available epidemiologic data and how they apply to our understanding of AKI pathophysiology during ECMO, identifies indications for RRT while on ECMO, reviews technical elements for RRT application in the setting of ECMO, and finally identifies specific research-focused questions that need to be addressed to improve outcomes in this at-risk population.
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Affiliation(s)
- David J Askenazi
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
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Oshima K, Kunimoto F, Hinohara H, Ohkawa M, Mita N, Tajima Y, Saito S. Extracorporeal membrane oxygenation for respiratory failure: Comparison of venovenous versus venoarterial bypass. Surg Today 2010; 40:216-22. [DOI: 10.1007/s00595-008-4040-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2008] [Accepted: 12/24/2008] [Indexed: 11/29/2022]
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Massaro AN, Rais-Bahrami K, Short BL. A tale of two bridges: effect of the bloodless bridge on renal function and blood pressure in neonates managed with venoarterial extracorporeal membrane oxygenation. Pediatr Crit Care Med 2009; 10:583-7. [PMID: 19741447 DOI: 10.1097/pcc.0b013e3181a70418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate if a change in bridge design of the extracorporeal membrane oxygenation (ECMO) circuit had an impact on renal function and blood pressure in neonates requiring venoarterial ECMO support. DESIGN : Retrospective chart review. SETTING A tertiary care neonatal intensive care unit and ECMO center. PATIENTS The medical records of neonates admitted to the neonatal intensive care unit and treated with venoarterial ECMO were reviewed. Data were collected on 50 consecutive neonates treated previous to (prebridge group) and following (postbridge group) transition to a new bridge design on the ECMO circuit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Gestational age, gender, racial distribution, and use of hypertensive therapy were similar between the two groups. Daily blood urea nitrogen, serum creatinine, urine output, fluid balance, and average and maximum systolic and mean arterial blood pressures were recorded for the first 3 days on bypass. The postbridge group had lower maximum mean arterial blood pressure and systolic blood pressure on day 2 of ECMO and lower average mean arterial blood pressure and systolic blood pressure on days 2 and 3 of ECMO. These differences remained significant after controlling for covariates in a multiple regression model. A higher percentage of patients were hypertensive (mean arterial blood pressure >60) in the prebridge group compared with the postbridge group. There were no differences in blood urea nitrogen, serum creatinine, fluid balance, and urine output between the two groups. CONCLUSIONS Patients managed on venoarterial ECMO after the transition to the "bloodless" bridge had less hypertension compared with those managed before the bridge change. This may reflect improved maintenance of renal perfusion associated with transition to an ECMO bridge design that does not require intermittent circulation with associated arterial-venous shunting.
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Affiliation(s)
- An N Massaro
- Department of Neonatology, Children's National Medical Center, Washington, DC, USA.
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Cavagnaro F, Kattan J, Godoy L, Gonzáles A, Vogel A, Rodríguez JI, Faunes M, Fajardo C, Becker P. Continuous renal replacement therapy in neonates and young infants during extracorporeal membrane oxygenation. Int J Artif Organs 2007; 30:220-6. [PMID: 17417761 DOI: 10.1177/039139880703000307] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a therapy that ensures adequate tissue oxygen delivery in patients suffering cardiac and/or respiratory failure that are unresponsive to conventional therapy. During ECMO, it is common to see a decrease in urine output that may be associated with acute renal failure. In this context, continuous renal replacement therapy (CRRT) should be considered. Our aim is to evaluate a pioneer experience in Latin America, related to the use of CRRT in a group of neonatal-pediatric patients during ECMO. We conducted a retrospective review of patients treated with ECMO at our institution between May 2003 and May 2005. Twelve infants were treated with ECMO, six of them also underwent CRRT. The main reasons for CRRT initiation were fluid overload and progressive azotemia. Observed complications were clots in the filter and excessive ultrafiltration. CRRT was successful in fluid management and solute clearance in all patients. Discharge survival rate was 83%, all of them with normal renal function. Concurrent CRRT with ECMO is technically feasible and efficacious in the management of fluid overload and solute clearance. We report the first experience with these therapies in a Latin American neonatal-pediatric ECMO program associated with the Extracorporeal Life Support Organization.
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Affiliation(s)
- F Cavagnaro
- Department of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Lira 85, Santiago, Chile.
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