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Cappelli J, Emling J, Edwards A, Babu A. Direct Apical Cannulation With Protek Duo Rapid Deployment Cannula via Mini Thoracotomy for Ambulatory Venoarterial-Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:565-569. [PMID: 38949771 DOI: 10.1097/mat.0000000000002157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
National trends show rapid increases in the use of mechanical circulatory support devices (MCSD) over the last 20 years. While current literature has not proven a mortality benefit in cardiogenic shock as a complication of acute myocardial infarction (AMI-CS) with percutaneous MCSD, these devices are vital to maximizing cardiopulmonary parameters for definitive therapy. To minimize complications, many different techniques have been described including a novel off-pump direct apical cannulation for venoarterial-extracorporeal membrane oxygenation (VA-ECMO). This technique allows early ambulation and avoids peripheral artery access complications but has only been described in small case series. Our case series represents the largest summary of patients (50) using this technique and contains the only comparison data to date. Fifty-four percentage of our patients were Society for Cardiovascular Angiography and Interventions (SCAI) stage D and 22% were arrested before cannulation. We achieved flows on average >5 L/min and most patients required biventricular drainage (86%) and an oxygenator (92%). Thirty day survival was 56% and most survivors were bridged to heart transplant (30%). Our most common complication was bleeding (16%). This technique showed significant improvement in ejection fraction (EF), cardiac output/index (CO/CI), and pulmonary artery pressures. This case series demonstrates the safety and efficacy of this novel technique for central cannulation in cardiogenic shock at large scale within a single institution.
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Affiliation(s)
- Jared Cappelli
- From the Department of General Surgery, University of Tennessee Health and Science Center - Nashville, Nashville, Tennessee
| | - Jonathan Emling
- Department of Cardiac Surgery, Ascension Saint Thomas Hospital West, Nashville, Tennessee
| | - Amber Edwards
- Department of Cardiac Surgery, Ascension Saint Thomas Hospital West, Nashville, Tennessee
| | - Ashok Babu
- Department of Cardiac Surgery, Ascension Saint Thomas Hospital West, Nashville, Tennessee
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van Galen DJM, Meinders Q, Halfwerk FR, Arens J. ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients. ASAIO J 2024; 70:377-386. [PMID: 38324706 PMCID: PMC11057491 DOI: 10.1097/mat.0000000000002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.
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Affiliation(s)
- Danny J. M. van Galen
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Quint Meinders
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Frank R. Halfwerk
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
- Department of Cardiothoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jutta Arens
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
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Yang J, Xie X, Li J, Li Y, Li B, Wang C, Jiang P. Which strategy is better for lung transplantation: Cardiopulmonary bypass or extracorporeal membrane oxygenation? Perfusion 2024:2676591241242018. [PMID: 38557237 DOI: 10.1177/02676591241242018] [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: 04/04/2024]
Abstract
Background: In lung transplantation surgery, extracorporeal life support (ECLS) is essential for safety. Various support methods, including cardiopulmonary bypass (CPB) and off-pump techniques, are used, with extracorporeal membrane oxygenation (ECMO) gaining prominence. However, consensus on the best support strategy is lacking.Purpose: This article reviews risks, benefits, and outcomes of different support strategies in lung transplantation. By consolidating knowledge, it aims to clarify selecting the most appropriate ECLS modality.Research Design: A comprehensive literature review examined CPB, off-pump techniques, and ECMO outcomes in lung transplantation, including surgical results and complications.Study Sample: Studies, including clinical trials and observational research, focused on ECLS in lung transplantation, both retrospective and prospective, providing a broad evidence base.Data Collection and/or Analysis: Selected studies were analyzed for surgical outcomes, complications, and survival rates associated with CPB, off-pump techniques, and ECMO to assess safety and effectiveness.Results: Off-pump techniques are preferred, with ECMO increasingly vital as a bridge to transplant, overshadowing CPB. However, ECMO entails hidden risks and higher costs. While safer than CPB, optimizing ECMO postoperative use and monitoring is crucial for success.Conclusions: Off-pump techniques are standard, but ECMO's role is expanding. Despite advantages, careful ECMO management is crucial due to hidden risks and costs. Future research should focus on refining ECMO use and monitoring to improve outcomes, emphasizing individualized approaches for LT recipients.
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Affiliation(s)
- Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Xinling Xie
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Li
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Bin Li
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Cheng Wang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Peng Jiang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
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Tonna JE, Boonstra PS, MacLaren G, Paden M, Brodie D, Anders M, Hoskote A, Ramanathan K, Hyslop R, Fanning JJ, Rycus P, Stead C, Barrett NA, Mueller T, Gómez RD, Kapoor PM, Fraser JF, Bartlett RH, Alexander PM, Barbaro RP. Extracorporeal Life Support Organization Registry International Report 2022: 100,000 Survivors. ASAIO J 2024; 70:131-143. [PMID: 38181413 PMCID: PMC10962646 DOI: 10.1097/mat.0000000000002128] [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] [Indexed: 01/07/2024] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) maintains the world's largest extracorporeal membrane oxygenation (ECMO) registry by volume, center participation, and international scope. This 2022 ELSO Registry Report describes the program characteristics of ECMO centers, processes of ECMO care, and reported outcomes. Neonates (0-28 days), children (29 days-17 years), and adults (≥18 years) supported with ECMO from 2009 through 2022 and reported to the ELSO Registry were included. This report describes adjunctive therapies, support modes, treatments, complications, and survival outcomes. Data are presented descriptively as counts and percent or median and interquartile range (IQR) by year, group, or level. Missing values were excluded before calculating descriptive statistics. Complications are reported per 1,000 ECMO hours. From 2009 to 2022, 154,568 ECMO runs were entered into the ELSO Registry. Seven hundred and eighty centers submitted data during this time (557 in 2022). Since 2009, the median annual number of adult ECMO runs per center per year increased from 4 to 15, whereas for pediatric and neonatal runs, the rate decreased from 12 to 7. Over 50% of patients were transferred to the reporting ECMO center; 20% of these patients were transported with ECMO. The use of prone positioning before respiratory ECMO increased from 15% (2019) to 44% (2021) for adults during the coronavirus disease-2019 (COVID-19) pandemic. Survival to hospital discharge was greatest at 68.5% for neonatal respiratory support and lowest at 29.5% for ECPR delivered to adults. By 2022, the Registry had enrolled its 200,000th ECMO patient and 100,000th patient discharged alive. Since its inception, the ELSO Registry has helped centers measure and compare outcomes across its member centers and strategies of care. Continued growth and development of the Registry will aim to bolster its utility to patients and centers.
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Affiliation(s)
- Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah
| | - Philip S. Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore, Singapore
| | - Matthew Paden
- Department of Surgery, Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Daniel Brodie
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Anders
- Department of Surgery, Division of Critical Care, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Aparna Hoskote
- Department of Surgery, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Surgery, Institute of Cardiovascular Science, University College London, Zayed Centre for Research into Rare Diseases in Children, London, UK
| | - Kollengode Ramanathan
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Surgery, Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rob Hyslop
- Department of Surgery, Heart Institute, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffrey J. Fanning
- Department of Pediatrics, Extracorporeal Life Support Program, Medical City Children’s Hospital, Dallas, Texas
| | - Peter Rycus
- Department of Surgery, Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan
| | - Christine Stead
- Department of Surgery, Extracorporeal Life Support Organization (ELSO), University of Michigan, Ann Arbor, Michigan
| | - Nicholas A. Barrett
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Surgery, Centre for Human & Applied Physiological Sciences, King’s College London, London, UK
| | - Thomas Mueller
- Intensive Care Medicine, Department of Internal Medicine II, University Hospital Regensburg, Germany
| | - Rene D. Gómez
- Department of Surgery, Terapias Avanzadas de Soporte Cardiopulmonar, Hospitales Tec Salud, Escuela de Medicina ITESM, Monterrey, Mexico
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology and Critical Care, Cardio Thoracic Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - John F. Fraser
- Department of Surgery, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | | | - Peta M.A. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
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5
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Critical Care and Occupational Therapy Practice Across the Lifespan. Am J Occup Ther 2023; 77:7713410220. [PMID: 38166053 DOI: 10.5014/ajot.2023.77s3003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
This AOTA Position Statement defines the distinct role and value of occupational therapy practitioners in critical care settings across the lifespan. Occupational therapy practitioners are essential interprofessional team members who address the needs of critically ill individuals by implementing evidence-based critical care guidelines that aim to improve the quality of survivorship.
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6
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Tonna JE, Bailey M, Abrams D, Brodie D, Hodgson CL. Predictors of early mobilization in patients requiring VV ECMO for greater than 7 days: An international cohort study. Heart Lung 2023; 62:57-63. [PMID: 37311360 PMCID: PMC10592536 DOI: 10.1016/j.hrtlng.2023.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Despite the demonstrated benefits of rehabilitation, active physical therapy and early mobilization are not universally performed during critical illness, especially among patients receiving extracorporeal membrane oxygenation (ECMO), with variation among sites. OBJECTIVE What factors are predictive of physical mobility during venovenous (VV) ECMO support? METHODS We performed an observational analysis of an international cohort using data from the Extracorporeal Life Support Organization (ELSO) Registry. We analyzed adults (≥18 years) supported with VV ECMO who survived for at least 7 days. Our primary outcome was early mobilization (ICU Mobility Scale score >0) at day 7 of ECMO support. Hierarchical multivariable logistic regression models were utilized to identify factors independently associated with early mobilization at day 7 of ECMO. Results are reported as adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). RESULTS Among 8,160 unique VV ECMO patients, factors independently associated with early mobilization included cannulation for transplantation (aOR 2.86 [95% CI 2.08-3.92]; p<0.001), avoidance of mechanical ventilation (aOR 0.51 [95% CI 0.41-0.64]; p<0.0001), higher center level patient volume (6-20 patients annually: aOR 1.49 [95% CI 1 to 2.23] and >20 patients annually: aOR 2 [95% CI: 1.37 to 2.93]; p<0.0001 for group), and cannulation with a dual-lumen cannula (aOR 1.25 [95% CI 1.08-1.42]; p = 0.0018). Early mobilization was associated with a lower probability of death (29 vs 48%; p<0.0001). CONCLUSIONS Higher levels of early mobilization on ECMO were associated modifiable and non-modifiable patient characteristics, including cannulation with a dual-lumen cannula, and with high center level patient volume.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, United States of America; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America.
| | - Michael Bailey
- Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Darryl Abrams
- Department of Medicine, Columbia University College of Physicians & Surgeons, United States of America; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, United States of America; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Physiotherapy, The Alfred, Melbourne, Australia; The George Institute for Global Health, Sydney, Australia; Department of Critical Care, The University of Melbourne, Melbourne, Australia
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7
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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8
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Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability. Crit Care Clin 2023; 39:255-275. [PMID: 36898772 DOI: 10.1016/j.ccc.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.
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9
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Wu YC, Chen CN. Physical Therapy for Adults with Heart Failure. Phys Ther Res 2023; 26:1-9. [PMID: 37181483 PMCID: PMC10169313 DOI: 10.1298/ptr.r0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/06/2023] [Indexed: 03/29/2023]
Abstract
Heart failure (HF) is a complex clinical syndrome caused by structural and/or functional abnormalities that results in significant disease burdens not only to the patients and their families but also to the society. Common symptoms/signs of HF include dyspnea, fatigue, and exercise intolerance, which significantly reduce the quality of life of individuals. Since the coronavirus disease 2019 (COVID-19) pandemic in 2019, it has been found that individuals with cardiovascular disease are more vulnerable to COVID-19-related cardiac sequelae including HF. In this article, we review the updated diagnosis, classifications, and interventional guidelines of HF. We also discuss the link between COVID-19 and HF. The latest evidence about physical therapy for patients with HF in both the stable chronic phase and acute cardiac decompensation phase is reviewed. Physical therapy for HF patients with circulatory support devices is also described.
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Affiliation(s)
- Yi-Chen Wu
- Department of Physical Therapy and Assistive Technology, School of Biomedical Science and Engineering, National Yang Ming Chiao Tung University, Taiwan
| | - Chiao-Nan Chen
- Department of Physical Therapy and Assistive Technology, School of Biomedical Science and Engineering, National Yang Ming Chiao Tung University, Taiwan
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10
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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11
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Chen Y, Li D, Liu Z, Liu Y, Fan H, Hou S. Research progress of portable extracorporeal membrane oxygenation. Expert Rev Med Devices 2023; 20:221-232. [PMID: 36846940 DOI: 10.1080/17434440.2023.2185136] [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: 03/01/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is primarily used for the supportive treatment of patients suffering from severe cardiopulmonary failure. With the continued development of ECMO technology, the relevant scenarios also extend pre-hospital and inter-hospital. In order to meet the needs of emergency treatment in communities, disaster sites and battlefields, inter-hospital transfer and evacuation; miniaturized and portable ECMO has become a current research hotspot. AREA COVERED The paper first introduces the principle, composition and common modes of ECMO and summarizes the research status of portable ECMO, Novalung and wearable ECMO, analyzes the characteristics and shortcomings of existing equipment. finally, we discussed the focus and development trend of portable ECMO technology. EXPERT OPINION Currently, portable ECMO has many applications in interhospital transport and there are various studies on portable and wearable ECMO devices, but the development of portable ECMO still faces many challenges. In the future, research related to integrated components, rich sensor arrays, Intelligent ECMO system and lightweight technology can make future portable ECMO more suitable for pre-hospital emergency and interhospital transport.
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Affiliation(s)
- Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Shike Hou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
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Chicano-Corrales A, Bañeras-Rius J, de Frutos F, Sánchez-Salado JC, Ariza-Solé A, Blasco-Lucas A, Sbraga F, Díez-López C, Calvo-Barriuso E, Castillo García J, Molina-Mazón CS, López-López A, Tinoco-Amorós I, Abellán-García A, González-Costello J. Impact of mobilization in patients with short-term mechanical circulatory support such as Levitronix® CentriMag as a bridge to heart transplantation. ENFERMERIA INTENSIVA 2023; 34:12-18. [PMID: 36774246 DOI: 10.1016/j.enfie.2022.03.002] [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: 06/22/2021] [Accepted: 03/10/2022] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Despite the benefits of mobilisation in the critical patient, the evidence in patients with Levitronix® CentriMag as a bridge to heart transplantation (HT) is scarce. The objective of this study is to analyze the impact of mobility on these patients. METHODS Retrospective observational study of patients who received a HT with Levitronix® CentriMag admitted between 2010 and 2019 to a tertiary hospital. Degree of mobility and nutritional status were assessed at the time of HT. Outcomes including infections, length of hospital admission and mortality were evaluated. RESULTS 27 patients were included and divided in two groups according to degree of mobility (22 with low mobility and 5 with high mobility). 90-day survival after HT was 63.6% in patients with low mobility and 80% in high mobility group; no statistically significant differences were observed. No differences were observed regarding ICU discharge after HT at 30 days. Nevertheless, lower albumin levels were observed in low mobility group (24,5 g/L (IQR: 23-30) vs 33 g/L (IQR: 26-36); p = .029). Invasive mechanical ventilation (IMV) post HT was longer in patients with low mobility (p = .014). There were no significant differences in appearance of pressure ulcers, or post HT infections among mobility groups. CONCLUSIONS Patients with high mobility had a shorter time of IMV and a better nutritional status. No complications were observed associated to mobility. No differences were observed between the degree of mobility and 90-day mortality, ICU stay or post HT adverse events.
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Affiliation(s)
- A Chicano-Corrales
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - J Bañeras-Rius
- Institut de Recerca del Hospital Vall d'Hebron, Servicio de Cardiología del Hospital Universitari Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
| | - F de Frutos
- Departamento de Cardiología del Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J C Sánchez-Salado
- Departamento de Cardiología del Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Ariza-Solé
- Institut de Recerca del Hospital Vall d'Hebron, Servicio de Cardiología del Hospital Universitari Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
| | - A Blasco-Lucas
- Departamento de Cirugía Cardíaca del Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - F Sbraga
- Departamento de Cirugía Cardíaca del Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - C Díez-López
- Departamento de Cardiología del Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - E Calvo-Barriuso
- Hemodinámica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Castillo García
- Perfusionista, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Facultad de Medicina y Ciencias de la Salud, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain
| | - C S Molina-Mazón
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Unidad de Electrofisiología y Arritmias, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Sistema de Emergencias Médicas de Cataluña, Spain
| | - A López-López
- Unidad Cuidados Intensivos, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - I Tinoco-Amorós
- Unidad de Cuidados Intensivos Cardiológicos y Hemodinámica, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - A Abellán-García
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J González-Costello
- Institut de Recerca del Hospital Vall d'Hebron, Servicio de Cardiología del Hospital Universitari Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
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Chicano-Corrales A, Bañeras-Rius J, de Frutos F, Sánchez-Salado J, Ariza-Solé A, Blasco-Lucas A, Sbraga F, Díez-López C, Calvo-Barriuso E, Castillo García J, Molina-Mazón C, López-López A, Tinoco-Amorós I, Abellán-García A, González-Costello J. Impacto de la movilización en pacientes portadores de soporte circulatorio mecánico de corta duración tipo Levitronix® CentriMag como puente a trasplante cardíaco. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Cucchi M, Mariani S, De Piero ME, Ravaux JM, Kawczynski MJ, Di Mauro M, Shkurka E, Hoskote A, Lorusso R. Awake extracorporeal life support and physiotherapy in adult patients: A systematic review of the literature. Perfusion 2022:2676591221096078. [PMID: 35760523 DOI: 10.1177/02676591221096078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is increasing. However, available evidence for this approach is limited, with unclear indications on timing, management, and protocols. This review summarizes available literature regarding Awake ECLS and physiotherapy application rates, practices, and outcomes in adults, providing indications for future investigations. METHODS Four databases were screened from inception to February 2021, for studies reporting adult Awake ECLS with/without physiotherapy. Primary outcome was hospital discharge survival, followed by Extracorporeal Membrane Oxygenation (ECMO) duration, extubation, Intensive Care Unit stay. RESULTS Twenty-nine observational studies and one randomized study were selected, including 1,157 patients (males n = 611/691, 88.4%) undergoing Awake ECLS. Support type was reported in 1,089 patients: Veno-Arterial ECMO (V-A = 39.6%), Veno-Venous ECMO (V-V = 56.8%), other ECLS (3.6%). Exclusive upper body cannulation and femoral cannulation were applied in 31% versus 69% reported cases (n = 931). Extubation was successful in 63.5% (n = 522/822) patients during ECLS. Physiotherapy details were given for 676 patients: exercises confined in bed for 47.9% (n = 324) patients, mobilization until standing in 9.3% (n = 63) cases, ambulation performed in 42.7% (n = 289) patients. Femoral cannulation, extubation and V-A ECMO were mostly correlated to complications. Hospital discharge survival observed in 70.8% (n = 789/1114). CONCLUSION Awake ECLS strategy associated with physiotherapy is performed regardless of cannulation approach. Ambulation, as main objective, is achieved in almost half the population examined. Prospective studies are needed to evaluate safety and efficacy of physiotherapy during Awake ECLS, and suitable patient selection. Guidelines are required to identify appropriate assessment/evaluation tools for Awake ECLS patients monitoring.
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Affiliation(s)
- Marta Cucchi
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Maria E De Piero
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Justine M Ravaux
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Michal J Kawczynski
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
| | - Emma Shkurka
- Cardiac Intensive Care Unit, 4956Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, 4956Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, and Cardiology Department, Heart and Vascular Center, 199236Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
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15
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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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16
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Driscoll J, Elkins J. Characteristics of Extracorporeal Membrane Oxygenation Education Vary in Entry-Level Doctor of Physical Therapy Programs. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Massart N, Mansour A, Flecher E, Ross JT, Ecoffey C, Verhoye JP, Launey Y, Auffret V, Nesseler N. Clinical Benefit of Extubation in Patients on Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2022; 50:760-769. [PMID: 34582413 DOI: 10.1097/ccm.0000000000005304] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock are usually supported with mechanical ventilation, it is not clear whether sedation cessation and extubation might improve outcomes. DESIGN Retrospective cohort study with propensity score overlap weighting analysis. SETTING Three ICUs in a 1,500-bed tertiary university hospital. PATIENTS From an overall cohort of 641 patients with venoarterial-extracorporeal membrane oxygenation support, the primary analysis was performed in 344 patients who had been successfully decannulated in order to reduce immortal time bias. MEASUREMENTS AND MAIN RESULTS Seventy-five patients (22%) were extubated during extracorporeal membrane oxygenation support and were subsequently decannulated alive. Forty-nine percent received noninvasive ventilation, and 25% had emergency reintubation for respiratory, neurologic, or hemodynamic reasons. Higher Simplified Acute Physiology Score II at admission (odds ratio, 0.97; 95% CI [0.95-0.99]; p = 0.008) was associated with a lower probability of extubation, whereas cannulation in cardiac surgery ICU (odds ratio, 3.14; 95% CI [1.21-8.14]; p = 0.018) was associated with an increased probability. Baseline characteristics were well balanced after propensity score overlap weighting. The number of ICU-free days within 30 days of extracorporeal membrane oxygenation decannulation was significantly higher among extubated patients compared with nonextubated patients (22 d [11-26 d] vs 18 d [7-25 d], respectively; p = 0.036). There were no differences in other outcomes including ventilator-associated pneumonia (odds ratio, 0.96; 95% CI [0.51-1.82]; p = 0.90) and all-cause mortality within 30 days of extracorporeal membrane oxygenation decannulation (5% vs 17%; hazard ratio, 0.54; 95% CI [0.19-1.59]; p = 0.27).As a secondary analysis, outcomes were compared in the overall cohort of 641 venoarterial extracorporeal membrane oxygenation-supported patients. Results were consistent with the primary analysis as extubated patients had a higher number of ICU-free days (18 d [0-24 d] vs 0 d [0-18 d], respectively; < 0.001) and a lower risk of death within 30 days of extracorporeal membrane oxygenation cannulation (hazard ratio, 0.45; 95% CI [0.29-0.71]; p = 0.001). CONCLUSIONS Extubation during venoarterial-extracorporeal membrane oxygenation support is safe, feasible, and associated with greater ICU-free days.
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Affiliation(s)
- Nicolas Massart
- Intensive-care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
| | - Alexandre Mansour
- Intensive-care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
| | - Erwan Flecher
- Intensive-care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
| | - James T Ross
- Intensive-care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
| | - Claude Ecoffey
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
| | | | - Yoann Launey
- Intensive-care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
| | - Vincent Auffret
- Intensive-care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, Rennes, France
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18
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Lee SH. Awakening in extracorporeal membrane oxygenation as a bridge to lung transplantation. Acute Crit Care 2022; 37:26-34. [PMID: 35279976 PMCID: PMC8918718 DOI: 10.4266/acc.2022.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/12/2022] [Indexed: 12/01/2022] Open
Abstract
Although the rate of lung transplantation (LTx), the last treatment option for end-stage lung disease, is increasing, some patients waiting for LTx need a bridging strategy for LTx due to the limited number of available donor lungs. For a long time, mechanical ventilation has been employed as a bridge to LTx because the outcome of using extracorporeal membrane oxygenation (ECMO) as a bridging strategy has been poor. However, the outcome after mechanical ventilation as a bridge to LTx was poor compared with that in patients without bridges. With advances in technology and the accumulation of experience, the outcome of ECMO as a bridge to LTx has improved, and the rate of ECMO use as a bridging strategy has increased over time. However, whether the use of ECMO as a bridge to LTx can achieve survival rates similar to those of non-bridged LTx patients remains controversial. In 2010, one center introduced awake ECMO strategy for LTx bridging, and its use as a bridge to LTx has been showing favorable outcomes to date. Awake ECMO has several advantages, such as maintenance of physical activity, spontaneous breathing, avoidance of endotracheal intubation, and reduced use of sedatives and analgesics, but it may cause serious problems. Nonetheless, several studies have shown that awake ECMO performed by a multidisciplinary team is safe. In cases where ECMO or mechanical ventilation is required due to unavoidable exacerbation in patients awaiting LTx, the application of awake ECMO performed by an appropriately trained ECMO multi-disciplinary team can be useful.
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Kourek C, Nanas S, Kotanidou A, Raidou V, Dimopoulou M, Adamopoulos S, Karabinis A, Dimopoulos S. Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support. J Cardiovasc Dev Dis 2022; 9:jcdd9020034. [PMID: 35200688 PMCID: PMC8875180 DOI: 10.3390/jcdd9020034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.
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Affiliation(s)
- Christos Kourek
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Serafim Nanas
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Anastasia Kotanidou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Vasiliki Raidou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Maria Dimopoulou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Stamatis Adamopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Andreas Karabinis
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Stavros Dimopoulos
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
- Correspondence: ; Tel.: +30-213-204-3389
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20
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Qi J, Gao S, Liu G, Yan S, Zhang M, Yan W, Zhang Q, Teng Y, Wang J, Zhou C, Wang Q, Ji B. An Ovine Model of Awake Veno-Arterial Extracorporeal Membrane Oxygenation. Front Vet Sci 2022; 8:809487. [PMID: 35004934 PMCID: PMC8735256 DOI: 10.3389/fvets.2021.809487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Large animal models are developed to help understand physiology and explore clinical translational significance in the continuous development of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) technology. The purpose of this study was to investigate the establishment methods and management strategies in an ovine model of VA-ECMO. Methods: Seven sheep underwent VA-ECMO support for 7 days by cannulation via the right jugular vein and artery. The animals were transferred into the monitoring cages after surgery and were kept awake after anesthesia recovery. The hydraulic parameters of ECMO, basic hemodynamics, mental state, and fed state of sheep were observed in real time. Blood gas analysis and activated clotting time (ACT) were tested every 6 h, while the complete blood count, blood chemistry, and coagulation tests were monitored every day. Sheep were euthanized after 7 days. Necropsy was performed and the main organs were removed for histopathological evaluation. Results: Five sheep survived and successfully weaned from ECMO. Two sheep died within 24-48 h of ECMO support. One animal died of fungal pneumonia caused by reflux aspiration, and the other died of hemorrhagic shock caused by bleeding at the left jugular artery cannulation site used for hemodynamic monitoring. During the experiment, the hemodynamics of the five sheep were stable. The animals stayed awake and freely ate hay and feed pellets and drank water. With no need for additional nutrition support or transfusion, the hemoglobin concentration and platelet count were in the normal reference range. The ECMO flow remained stable and the oxygenation performance of the oxygenator was satisfactory. No major adverse pathological injury occurred. Conclusions: The perioperative management strategies and animal care are the key points of the VA-ECMO model in conscious sheep. This model could be a platform for further research of disease animal models, pathophysiology exploration, and new equipment verification.
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Affiliation(s)
- Jiachen Qi
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Min Zhang
- Beijing Key Laboratory of Pre-clinical Research and Evaluation for Cardiovascular Implant Materials, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Weidong Yan
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qiaoni Zhang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuan Teng
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jian Wang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chun Zhou
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qian Wang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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21
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Andersen EM, Kelly TL, Sharp A, Keller-Ross ML, Brunsvold ME. Active Rehabilitation in a Patient During and After Venovenous Extracorporeal Membrane Oxygenation With a Diagnosis of COVID-19: A Case Report. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022; 13:8-15. [PMID: 34925957 PMCID: PMC8670079 DOI: 10.1097/jat.0000000000000164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/21/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE The coronavirus disease-2019 (COVID-19) pandemic has resulted in an influx of critically ill patients requiring mechanical ventilation, some receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). The benefits of early mobility while undergoing ECMO have been previously documented. However, the COVID-19 pandemic has presented physical therapists with novel challenges, balancing the risk of a widespread shortage of personal protective equipment (PPE) with the benefits of early mobility for patients on ECMO. The purpose of this case study is to report the successful rehabilitation of a critically ill patient with COVID-19 undergoing VV ECMO. METHODS This is a case description of a 38-year-old man who presented to the hospital with COVID-19 and subsequent intubation and cannulation for VV ECMO. Physical therapy was initiated while the patient remained critically ill on VV ECMO. Focused coordination and education were employed to limit PPE usage by limiting the number of essential staff/therapists that entered the room as well as changing the frequency of therapy sessions dependent on how the patient was progressing functionally. RESULTS On VV ECMO day 11, he was able to sit up and perform a sit-to-stand. ECMO decannulation occurred on hospital day 14 with extubation on hospital day 18. The patient progressed functionally while quarantined in the room until he was discharged home with supplemental oxygen after spending 29 days in the hospital. CONCLUSION This case study demonstrates the clinical decision-making used to provide physical therapy services for a critically ill patient with COVID-19. High-level team coordination resulted in limiting the use of PPE as well as reducing staff exposure frequency during rehabilitation. Despite his severe critical illness, the patient was successfully discharged home within 30 days.
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Affiliation(s)
- Eric M Andersen
- M Health Fairview, Minneapolis, MN 55455 (USA).
- M Health Fairview, Minneapolis, Minnesota
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Surgery, Division of Acute Care Surgery, Medical School, University of Minnesota, Minneapolis
| | - Tara L Kelly
- M Health Fairview, Minneapolis, MN 55455 (USA).
- M Health Fairview, Minneapolis, Minnesota
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Surgery, Division of Acute Care Surgery, Medical School, University of Minnesota, Minneapolis
| | - Amanda Sharp
- M Health Fairview, Minneapolis, MN 55455 (USA).
- M Health Fairview, Minneapolis, Minnesota
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Surgery, Division of Acute Care Surgery, Medical School, University of Minnesota, Minneapolis
| | - Manda L Keller-Ross
- M Health Fairview, Minneapolis, MN 55455 (USA).
- M Health Fairview, Minneapolis, Minnesota
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Surgery, Division of Acute Care Surgery, Medical School, University of Minnesota, Minneapolis
| | - Melissa E Brunsvold
- M Health Fairview, Minneapolis, MN 55455 (USA).
- M Health Fairview, Minneapolis, Minnesota
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Rehabilitation Medicine, Division of Physical Therapy, Medical School, University of Minnesota, Minneapolis
- Department of Surgery, Division of Acute Care Surgery, Medical School, University of Minnesota, Minneapolis
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22
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Obradovic D, Freund A, Feistritzer HJ, Sulimov D, Loncar G, Abdel-Wahab M, Zeymer U, Desch S, Thiele H. Temporary mechanical circulatory support in cardiogenic shock. Prog Cardiovasc Dis 2021; 69:35-46. [PMID: 34801576 DOI: 10.1016/j.pcad.2021.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
Cardiogenic shock (CS) represents one of the foremost concerns in the field of acute cardiovascular medicine. Despite major advances in treatment, mortality of CS remains high. International societies recommend the development of expert CS centers with standardized protocols for CS diagnosis and treatment. In these terms, devices for temporary mechanical circulatory support (MCS) can be used to support the compromised circulation and could improve clinical outcome in selected patient populations presenting with CS. In the past years, we have witnessed an immense increase in the utilization of MCS devices to improve the clinical problem of low cardiac output. Although some treatment guidelines include the use of temporary MCS up to now no large randomized controlled trial confirmed a reduction in mortality in CS patients after MCS and additional research evidence is necessary to fully comprehend the clinical value of MCS in CS. In this article, we provide an overview of the most important diagnostic and therapeutic modalities in CS with the main focus on contemporary MCS devices, current state of art and scientific evidence for its clinical application and outline directions of future research efforts.
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Affiliation(s)
- Danilo Obradovic
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Hans-Josef Feistritzer
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Dmitry Sulimov
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Goran Loncar
- Institute for Cardiovascular Diseases 'Dedinje', University of Belgrade, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Mohamed Abdel-Wahab
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Uwe Zeymer
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany.
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Polastri M, Swol J, Loforte A, Dell'Amore A. Extracorporeal membrane oxygenation and rehabilitation in patients with COVID-19: A scoping review. Artif Organs 2021; 46:30-39. [PMID: 34778984 PMCID: PMC8652633 DOI: 10.1111/aor.14110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022]
Abstract
Background and purpose The coronavirus diseases 2019 (COVID‐19) pandemic posed severe difficulties in managing critically ill patients in hospital care settings. Extracorporeal membrane oxygenation (ECMO) support has been proven to be lifesaving support during the SARS‐CoV‐2 outbreak. The purpose of this review was to describe the rehabilitative treatments provided to patients undergoing ECMO support during the COVID‐19 pandemic. Methods We searched PubMed and Scopus for English‐language studies published from the databases’ inception until June 30, 2021. We excluded editorials, letters to the editor, and studies that did not describe rehabilitative procedures during ECMO support. We also excluded those articles not written in English. Results A total of 50 articles were identified. We ultimately included nine studies, seven of which were case reports. Only two studies had more than one patient; an observational design analyzing the clinical course of 19 patients and a case series of three patients. Extracorporeal support duration varied from 9 to 49 days, and the primary indication was acute respiratory distress syndrome COVID‐19‐related. Rehabilitative treatment mainly consisted of in‐bed mobilization, postural transfers (including sitting), and respiratory exercises. After hospital discharge, patients were referred to rehabilitation facilities. Physiotherapeutic interventions provided during ECMO support and after its discontinuation were feasible and safe. Conclusion The physiotherapeutic treatment of patients undergoing ECMO support includes several components and must be provided in a multidisciplinary context. The optimal approach depends on the patient’s status, including sedation, level of consciousness, ECMO configuration, types of cannulas, and cannulation site.
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Affiliation(s)
- Massimiliano Polastri
- Department of Continuity of Care and Disability, Physical Medicine and Rehabilitation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola University Hospital, Bologna, Italy
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University General Hospital, Nuremberg, Germany
| | - Antonio Loforte
- Department of Cardiac, Thoracic, Vascular Diseases, Cardiac Surgery and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola University Hospital, Bologna, Italy
| | - Andrea Dell'Amore
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Division of Thoracic Surgery, University of Padua, Padua, Italy
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Mustafa AK, Joshi DJ, Alexander PJ, Tabachnick DR, Cross CA, Jweied EE, Mody NS, Huh MH, Fasih S, Pappas PS, Tatooles AJ. Comparative Propensity Matched Outcomes in Severe COVID-19 Respiratory Failure-Extracorporeal Membrane Oxygenation or Maximum Ventilation Alone. Ann Surg 2021; 274:e388-e394. [PMID: 34617934 PMCID: PMC8500214 DOI: 10.1097/sla.0000000000005187] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Does extracorporeal membrane oxygenation (ECMO) improve outcomes in ECMO-eligible patients with COVID-19 respiratory failure compared to maximum ventilation alone (MVA)? SUMMARY BACKGROUND DATA ECMO is beneficial in severe cases of respiratory failure when mechanical ventilation is inadequate. Outcomes for ECMO-eligible COVID-19 patients on MVA have not been reported. Consequently, a direct comparison between COVID-19 patients on ECMO and those on MVA has not been established. METHODS A total of 3406 COVID-19 patients treated at two major medical centers in Chicago were studied. One hundred ninety-five required maximum ventilatory support, and met ECMO eligibility criteria. Eighty ECMO patients were propensity matched to an equal number of MVA patients using detailed demographic, physiological, and comorbidity data. Primary outcome was survival and disposition at discharge. RESULTS Seventy-one percent of patients were decannulated from ECMO. Mechanical ventilation was discontinued in 75% ECMO and 16% MVA patients. Twenty-five percent of patients in the ECMO arm expired, 21% while on ECMO, compared with 74% in the MVA cohort. Mortality was significantly lower across all age and BMI groups in the ECMO arm. Sixty-eight percent ECMO and 26% MVA patients were discharged from the hospital. Fewer ECMO patients required long-term rehabilitation. Major complications such as septic shock, ventilator associated pneumonia, inotropic requirements, acute liver and kidney injuries are less frequent among ECMO patients. CONCLUSIONS ECMO-eligible patients with severe COVID-19 respiratory failure demonstrate a 3-fold improvement in survival with ECMO. They are also in a better physical state at discharge and have lower overall complication rates. As such, strong consideration should be given for ECMO when mechanical ventilatory support alone becomes insufficient in treating COVID-19 respiratory failure.
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Affiliation(s)
- Asif K Mustafa
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Devang J Joshi
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Philip J Alexander
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Deborah R Tabachnick
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Chadrick A Cross
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Eias E Jweied
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Nitesh S Mody
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL
| | - Marc H Huh
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL
| | - Subia Fasih
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL
| | - Pat S Pappas
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
| | - Antone J Tatooles
- Cardiothoracic and Vascular Surgical Associates, S.C., Advocate Christ Medical Center, Oak Lawn, IL
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, IL
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Rehabilitation of adult patients on extracorporeal membrane oxygenation: A scoping review. Aust Crit Care 2021; 35:575-582. [PMID: 34711492 DOI: 10.1016/j.aucc.2021.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The objective of this study was to conduct a scoping review to comprehensively map the breadth of literature related to the rehabilitation of adult patients whilst on extracorporeal membrane oxygenation (ECMO) and identify gaps and areas for future research. REVIEW METHOD USED This review was conducted using recommended frameworks for methods and reporting including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. DATE SOURCES We searched seven databases from inception to June 2021 and included all study designs and grey literature. REVIEW METHODS Eligibility screening was completed by two independent reviewers according to inclusion and exclusion criteria, with any disagreement resolved by consensus or with consultation with a third reviewer. Two independent reviewers extracted data related to intervention characteristics, patient outcomes, feasibility, safety, hospital outcomes, and mortality using a custom-designed piloted form. RESULTS Of 8507 records, 185 original studies met inclusion criteria, with the majority being small retrospective studies. Rehabilitation was more commonly reported in patients on veno-venous rather than veno-arterial ECMO. Ambulation was the most commonly reported intervention (51% of studies). Critical gaps were identified including incomplete reporting of the intervention along with heterogeneity in the type and timing of outcome measures. Less than 50% of patients met eligibility criteria to participate, but screening for eligibility was infrequently reported (9% of studies). Delivery of rehabilitation during ECMO may be facilitated by an expert multidisciplinary team, along with a strategy that targets low sedation levels and an upper body cannulation approach. CONCLUSIONS Rehabilitation during ECMO is an emerging area of research and mostly consisted of small retrospective single-centre studies. Future research requires more robust methodological designs that include comprehensive screening of potential candidates with reporting of eligibility, more detailed descriptions of the rehabilitation interventions, inclusion of a core outcome set with defined measurement instruments, and consistent timing of outcome measurement.
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Knudson KA, Funk M, Redeker NS, Andrews LK, Whittemore R, Mangi AA, Sadler LS. An unbelievable ordeal: The experiences of adult survivors treated with extracorporeal membrane oxygenation. Aust Crit Care 2021; 35:391-401. [PMID: 34474961 DOI: 10.1016/j.aucc.2021.06.010] [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: 09/28/2020] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue treatment option for adult patients with severe cardiac dysfunction or respiratory failure. While short-term patient outcomes, such as in-hospital mortality and complications, have been widely described, little is known about the illness or recovery experience from the perspectives of survivors. Subjective reports of health are important indicators of the full, long-term impact of critical illness and treatment with ECMO on survivors' lives. OBJECTIVE The objective of this study was to describe the experiences and needs of adults treated with ECMO, from onset of illness symptoms through the process of survivorship. METHODS This study was guided by the qualitative method of interpretive description. We conducted in-depth, semistructured interviews with 16 adult survivors of ECMO who were treated at two participating regional ECMO centres in the northeast United States. Additional data were collected from demographic questionnaires, field notes, memos, and medical record review. Development of interview guides and data analysis were informed by the Family Management Style Framework. Qualitative data were analysed using thematic analysis techniques. RESULTS The sample (n = 16) included 75% male participants; ages ranged from 23 to 65 years. Duration from hospital discharge to interviews ranged from 11 to 90 (M = 54; standard deviation = 28) months. Survivors progressed through three stages: Trauma and Vulnerability, Resiliency and Recovery, and Survivorship. Participants described short- and long-term impacts of the ECMO experience: all experienced physical challenges, two-thirds had at least one psychological or cognitive difficulty, and 25% were unable to return to work. All were deeply influenced by their own specific contexts, family support, and interactions with healthcare providers. CONCLUSIONS The ECMO experience is traumatic and complex. Recovery requires considerable time, perseverance, and support. Long-term sequelae include impairments in cognitive, mental, emotional, physical, and social health. Survivors could likely benefit from specialised posthospital health services that include integrated, comprehensive follow-up care.
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Affiliation(s)
- Krista A Knudson
- Institute for Translational Medicine, University of Chicago, 5841 S. Maryland Ave, W511, MC7100, Chicago, IL, 60637, United States; Rush University, 600 S. Paulina St, Chicago, IL, 60612, United States; Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Marjorie Funk
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Nancy S Redeker
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Laura K Andrews
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Robin Whittemore
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Abeel A Mangi
- Yale School of Medicine, 300 Cedar Street, New Haven, CT, 06511, United States; MedStar Heart and Vascular Institute, Suite 6D-15, 110 Irving Street NW, Washington, DC, 20010, United States.
| | - Lois S Sadler
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
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Lorusso R, Shekar K, MacLaren G, Schmidt M, Pellegrino V, Meyns B, Haft J, Vercaemst L, Pappalardo F, Bermudez C, Belohlavek J, Hou X, Boeken U, Castillo R, Donker DW, Abrams D, Ranucci M, Hryniewicz K, Chavez I, Chen YS, Salazar L, Whitman G. ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients. ASAIO J 2021; 67:827-844. [PMID: 34339398 DOI: 10.1097/mat.0000000000001510] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Kiran Shekar
- Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Graeme MacLaren
- Cardio-Thoracic Intensive Care Unit, National University Hospital, Singapore, Singapore
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Hopital La Pitie'-Salpetriere, University Pierre et Marie Curie, Paris, France
| | - Vincent Pellegrino
- Intensive Care Unit, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Bart Meyns
- Cardiac Surgery Unit, Gasthuisberg University Hospital, Catholic University, Leuven, Belgium
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Leen Vercaemst
- Cardiac Surgery Unit, Gasthuisberg University Hospital, Catholic University, Leuven, Belgium
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC, Palermo, Italy
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jan Belohlavek
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Xiaotong Hou
- Cardiac Intensive Care, Beijing Anzhem Hospital, Capital Medical University, Beijing, China
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - Dirk W Donker
- Intensive Care Unit, Utrecht University Medical Centre, Utrecht, The Netherlands
- CRPH Cardiovascular & Respiratory Physiology Group, TechMed Centre, Faculty of Science & Technology, University of Twente, Enschede, The Netherlands
| | - Darryl Abrams
- Division of Pulmonology, Allergy and Critical Care, NewYork Presbiterian Hospital, Columbia University, New York, New York
| | - Marco Ranucci
- Cardio-Thoracic and Vascular Anesthesia and ICU Department, IRCCS Policlinico San Donato Hospital, Milan, Italy
| | - Kasia Hryniewicz
- Minneapolis Heart Institute Foundation, Abbot Northwestern University, Minneapolis, Minnesota
| | - Ivan Chavez
- Minneapolis Heart Institute Foundation, Abbot Northwestern University, Minneapolis, Minnesota
| | - Yih-Sharng Chen
- Cardiovascular Centre, National Taiwan University Hospital, Taiwan, Taipei
| | - Leonardo Salazar
- Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit and Heart Transplant, Johns Hopkins Hospital, Baltimore, Maryland
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Early Mobilization during ECMO for Cardiopulmonary Failure in Adults: Factors Associated with Intensity of Treatment. Ann Am Thorac Soc 2021; 19:90-98. [PMID: 34077700 DOI: 10.1513/annalsats.202102-151oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Early mobilization of ECMO-supported patients is increasingly common, but it remains unknown whether there are factors predictive of achieving higher intensity mobilization among those able to participate in physical therapy. Additionally, data regarding the safety and feasibility of early mobilization with femoral cannulation, particularly ambulation, are sparse. OBJECTIVES To determine whether there are factors associated with achieving out-of-bed versus in-bed physical therapy in ECMO-supported patients participating in physical therapy, and whether mobilization with femoral cannulation is safe and feasible. METHODS This large, single-center, retrospective study evaluated adult patients who performed active physical therapy while receiving ECMO. Mixed effects modeling was used to identify predictors of out-of-bed versus in-bed activity. Rates of mobilization with femoral cannulation and adverse events were also reported. RESULTS Between April 2009 and January 2020, 511 patients were supported with ECMO in a single medical intensive care unit, of whom 177 (35%) underwent active physical therapy and were included in the analysis, including 124 of 141 (88%) bridge-to-lung transplantation and 53 of 370 (14%) bridge-to-recovery. These 177 patients accounted for 2706 active physical therapy sessions, with 138 patients (78%) achieving out-of-bed activity. One hundred eight (61%) patients ambulated (1284 sessions), 34 of whom had femoral cannulae (250 sessions). Bridge-to-transplant (OR 17.2, 95% CI [4.12-72.1]), venovenous ECMO (OR 2.83, 95% CI [1.29-6.22]), later cannulation year (OR 1.65, 95% CI [1.37-1.98]) and higher Charlson Comorbidity Index (OR 1.53, 95% CI [1.07-2.19]) were associated with increased odds of achieving out-of-bed versus in-bed physical therapy, whereas invasive mechanical ventilation (OR 0.11, 95% CI [0.05-0.25]) and femoral cannulation (OR 0.19, 95% CI [0.04-0.92) were associated with decreased odds of performing out-of-bed activities. Adverse events occurred in 2% of sessions. CONCLUSIONS Several patient- and ECMO-related factors were associated with achieving higher intensity of early mobilization in those participating in rehabilitation. Physical therapy with femoral cannulation was safe and feasible, and complications related to mobilization were uncommon.
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29
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Tonna JE, Abrams D, Brodie D, Greenwood JC, Rubio Mateo-Sidron JA, Usman A, Fan E. Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO J 2021; 67:601-610. [PMID: 33965970 PMCID: PMC8315725 DOI: 10.1097/mat.0000000000001432] [Citation(s) in RCA: 236] [Impact Index Per Article: 78.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Disclaimer: The use of venovenous extracorporeal membrane oxygenation (VV ECMO) in adults has rapidly increased worldwide. This ELSO guideline is intended to be a practical guide to patient selection, initiation, cannulation, management, and weaning of VV ECMO for adult respiratory failure. This is a consensus document which has been updated from the previous version to provide guidance to the clinician.
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Affiliation(s)
- Joseph E Tonna
- From the Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - John C Greenwood
- Department of Anesthesiology and Critical Care, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Asad Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network and Sinai Health System, Toronto, Canada
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30
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Early rehabilitation during extracorporeal membrane oxygenation has minimal impact on physiological parameters: A pilot randomised controlled trial. Aust Crit Care 2021; 34:217-225. [DOI: 10.1016/j.aucc.2020.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022] Open
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Patangi SO, Shetty RS, Shanmugasundaram B, Kasturi S, Raheja S. Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock' - A review with an Indian perspective. Indian J Thorac Cardiovasc Surg 2021; 37:275-288. [PMID: 33191992 PMCID: PMC7647874 DOI: 10.1007/s12055-020-01051-7] [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: 06/23/2020] [Revised: 08/14/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve 'milieu intérieur'. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.
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Affiliation(s)
- Sanjay Orathi Patangi
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Riyan Sukumar Shetty
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Balasubramanian Shanmugasundaram
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, 258/A Hosur Road, Bommasandra Industrial Area, Anekal Taluk, Bengaluru, Karnataka 560099 India
| | - Srikanth Kasturi
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Shivangi Raheja
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, India
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Das S, Gupta S, Das D, Dutta N. Basics of extra corporeal membrane oxygenation: a pediatric intensivist's perspective. Perfusion 2021; 37:439-455. [PMID: 33765881 DOI: 10.1177/02676591211005260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Extra Corporeal membrane oxygenation (ECMO) is one of the most advanced forms of life support therapy in the Intensive Care Unit. It relies on the principle where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) within which blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. The goal of ECMO is to provide a physiologic milieu for recovery in refractory cardiac/respiratory failure. The technology is not a definitive treatment for a disease, but provides valuable time for the body to recover. In that way it can be compared to a bridge, where patients are initiated on ECMO as a bridge to recovery, bridge to decision making, bridge to transplant or bridge to diagnosis. The use of this modality in children is not backed by a lot of randomized controlled trials, but the use has increased dramatically in our country in last 10 years. This article is not intended to provide an in-depth overview of ECMO, but outlines the basic principles that a pediatric intensive care physician should know in order to manage a kid on ECMO support.
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Affiliation(s)
- Shubhadeep Das
- Department of Pediatric Cardiac Intensive Care, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Sandip Gupta
- Department of Pediatric Intensive Care, Aster CMI Hospital, Bangalore, Karnataka, India
| | - Debasis Das
- Department of Cardiac Surgery, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Nilanjan Dutta
- Department of Cardiac Surgery, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
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Tukacs M, Cato KD. Extubation during extracorporeal membrane oxygenation in adults: An international qualitative study on experts' opinions. Heart Lung 2021; 50:299-306. [PMID: 33482432 DOI: 10.1016/j.hrtlng.2021.01.010] [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: 10/15/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation in adults (adult-ECMO), a modification of cardiopulmonary bypass is increasingly used. Liberation from mechanical ventilation, or extubation, during adult-ECMO remains a challenge. OBJECTIVES This study aimed to understand expert perceptions of the reasonableness of extubation during adult-ECMO and the usefulness of an extubation clinical practice guideline (ECPG). METHODS Homogeneous purposive sampling, focus groups, and interviews with a discussion guide, and direct content, thematic analysis were used. RESULTS Fourteen volunteers participated with different educational levels (79% Doctor of Medicine, 14% Registered Nurse, 7% Nurse Practitioner), from high-volume ECMO centers of various annual ECMO runs (50% 30-49 ECMO/year, 36% 50-99 ECMO/year, 14% >100 ECMO/year) worldwide (64% North America, 21% South America, 7% Europe, 7% Asia). Seven themes were identified: paucity of evidence, mindsets towards using an ECPG, barriers, criteria and benefits of extubation, culture towards extubation and vision of the future. Participants recommended aiming for extubation based on patient selection, and a standardized extubation approach with an ECPG or team decision-making. CONCLUSION Application of adult-ECMO is expanding, during which extubation remains difficult. Experts recommend two methods of a standardized extubation approach.
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Affiliation(s)
- Monika Tukacs
- Department of Cardiothoracic Intensive Care Unit, NewYork-Presbyterian/Columbia University Irving Medical Center, 177 Fort Washington Ave, New York, NY 10032, United States; Department of Nursing, NewYork-Presbyterian/Columbia University Irving Medical Center, 177 Fort Washington Ave, New York, NY 10032, United States.
| | - Kenrick D Cato
- Department of Nursing Administration, NewYork-Presbyterian/Columbia University Irving Medical Center, 177 Fort Washington Ave, New York, NY 10032, United States; Faculty, Columbia University School of Nursing, 560W 168th St, New York, NY 10032, United States
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Haji JY, Mehra S, Doraiswamy P. Awake ECMO and mobilizing patients on ECMO. Indian J Thorac Cardiovasc Surg 2021; 37:309-318. [PMID: 33487891 PMCID: PMC7811888 DOI: 10.1007/s12055-020-01075-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 01/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving technology in critically ill patients who present with cardiac/pulmonary/combined cardiopulmonary failure. These patients are the sickest of all patients in any critical care unit and will invariably have a prolonged course and rehabilitation. Spontaneous breathing and early mobilization can reduce the intensive care unit (ICU)-acquired weakness, improve functional recovery, and reduce superadded infections and length of stay in the hospital, thus decreasing the cost of treatment. In low socioeconomic countries, there is an associated challenge of the availability of specially trained personnel necessary to manage patients on ECMO. Managing and ambulating an awake patient on ECMO is very labour-intensive and poses various challenges. Every ECMO program should aim to develop goals, methods, and protocols to this end. These can be derived from best practices worldwide by suitably adapting to available personnel and equipment. In this review, we aim to highlight the advantages and associated challenges of awake ECMO and describe protocols to aid safe ambulation and physiotherapy for ECMO patients. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-020-01075-z.
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Affiliation(s)
- Jumana Yusuf Haji
- Aster CMI Hospital Bangalore, 43/2, New Airport Road, NH.7, Sahakara Nagar, Bengaluru, Karnataka 560092 India
| | - Sanyam Mehra
- Aster CMI Hospital Bangalore, 43/2, New Airport Road, NH.7, Sahakara Nagar, Bengaluru, Karnataka 560092 India
| | - Prakash Doraiswamy
- Aster CMI Hospital Bangalore, 43/2, New Airport Road, NH.7, Sahakara Nagar, Bengaluru, Karnataka 560092 India
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Levin NM, Ciullo AL, Overton S, Mitchell N, Skidmore CR, Tonna JE. Characteristics of Patients Managed without Positive Pressure Ventilation While on Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. J Clin Med 2021; 10:jcm10020251. [PMID: 33445504 PMCID: PMC7827358 DOI: 10.3390/jcm10020251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Extracorporeal membrane oxygenation (ECMO) has expanding indications for cardiopulmonary resuscitation including severe acute respiratory distress syndrome (ARDS). Despite the adjunct of ECMO for patients with severe ARDS, they often have prolonged mechanical ventilation and are subject to many of its inherent complications. Here, we describe patients who were cannulated for venovenous (VV) ECMO and were taken off positive pressure ventilation. Methods: This is a primary analysis of patients admitted at a tertiary medical center between the dates of August 2014 to January 2020 who were cannulated to ECMO for refractory respiratory failure. We included all patients ≥18 years old. Patients who were extubated or had a tracheostomy and taken off positive pressure while on ECMO were classified as “off positive pressure ventilation (PPV)” and were compared to patients who remained “on PPV” while on ECMO. Primary outcome was survival to hospital discharge. Secondary outcomes were ventilator free days at 30 days and 60 days after ECMO cannulation, time from cannulation to date of first out-of-bed (OOB), and hospital length of stay (LOS). Patient characteristics were derived from routine clinical information in the electronic health record (EHR). Categorical characteristics were compared using chi-square test or Fisher exact test. Continuous characteristics were compared using independent samples t-test or Wilcoxon–Mann–Whitney test. p-values were reported from all analysis. Results: Sixty-five patients were included in this retrospective analysis. Forty-eight were managed on ECMO with PPV and 17 patients were removed from PPV. Patients removed from PPV had significantly higher lung injury scores prior to cannulation (2.5 ± 0.6 vs. 1.04 ± 0.3; p = 0.031) and non-significantly longer duration of ventilation prior to ECMO (6.1 days ± 2.1 vs. 5.0 days ± 01.1; p = 0.634). One hundred percent (100%) of patients removed from PPV survived to hospital discharge compared to 45% who received PPV throughout their duration of ECMO management (p < 0.001). The mean ventilator free days at day 60 was 15 with PPV and 36 without PPV (p = 0.003). The average duration from cannulation to mobilization (i.e., out-of-bed) was 18 days with PPV and 7 days without PPV (p = 0.015). Conclusions: Patients taken off PPV while on ECMO had a very high likelihood of survival to discharge and were mobilized in half as many days. While this likely reflects patient selection, the benefit of early mobilization is well documented and the approach of extubating while on ECMO warrants further investigation.
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Affiliation(s)
- Nicholas M Levin
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA; (N.M.L.); (A.L.C.); (N.M.)
| | - Anna L Ciullo
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA; (N.M.L.); (A.L.C.); (N.M.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA;
| | - Sean Overton
- Division of Critical Care, Department of Anesthesiology, University of Utah Health, Salt Lake City, UT 84132, USA;
| | - Nathan Mitchell
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA; (N.M.L.); (A.L.C.); (N.M.)
| | - Chloe R Skidmore
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA;
| | - Joseph E Tonna
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA; (N.M.L.); (A.L.C.); (N.M.)
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA;
- Correspondence: ; Tel.: +1-801-587-9373
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Braune S, Bojes P, Mecklenburg A, Angriman F, Soeffker G, Warnke K, Westermann D, Blankenberg S, Kubik M, Reichenspurner H, Kluge S. Feasibility, safety, and resource utilisation of active mobilisation of patients on extracorporeal life support: a prospective observational study. Ann Intensive Care 2020; 10:161. [PMID: 33259044 PMCID: PMC7708587 DOI: 10.1186/s13613-020-00776-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 11/20/2020] [Indexed: 11/29/2022] Open
Abstract
Background There is scarce evidence on the feasibility, safety and resource utilisation of active mobilisation in critically ill patients on extracorporeal life support (ECLS). Methods This prospective observational single-centre study included all consecutive critically ill patients on ECLS admitted to an academic centre in Germany over a time period of one year. The level of mobilisation was categorised according to the ICU Mobility Scale (IMS). Primary outcome was complications during mobilisation. Results During the study period, active mobilisation with an activity level on the IMS of ≥ 3 was performed at least on one occasion in 43 out of 115 patients (37.4%). A total of 332 mobilisations with IMS ≥ 3 were performed during 1242 ECLS days (26.7%). ECLS configurations applied were va-ECMO (n = 63), vv-ECMO (n = 26), vv-ECCO2R (n = 12), av-ECCO2R (n = 10), and RVAD (n = 4). Femoral cannulation had been in place in 108 patients (93.9%). The median duration of all mobilisation activities with IMS ≥ 3 was 130 min (IQR 44–215). All mobilisations were undertaken by a multi-professional ECLS team with a median number of 3 team members involved (IQR 3–4). Bleeding from cannulation site requiring transfusion and/or surgery occurred in 6.9% of actively mobilised patients and in 15.3% of non-mobilised patients. During one mobilisation episode, accidental femoral cannula displacement occurred with immediate and effective recannulation. Sedation was the major reason for non-mobilisation. Conclusions Active mobilisation (IMS ≥ 3) of ECLS patients undertaken by an experienced multi-professional team was feasible, and complications were infrequent and managed successfully. Larger prospective multicentre studies are needed to further evaluate early goal directed sedation and mobilisation bundles in patients on ECLS.
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Affiliation(s)
- Stephan Braune
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Patrick Bojes
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Anne Mecklenburg
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Gerold Soeffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Katja Warnke
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dirk Westermann
- Department of Interventional and General Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Interventional and General Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Mathias Kubik
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Li T, Yin PF, Li A, Shen MR, Yao YX. Acute Respiratory Distress Syndrome Treated With Awake Extracorporeal Membrane Oxygenation in a Patient With COVID-19 Pneumonia. J Cardiothorac Vasc Anesth 2020; 35:2467-2470. [PMID: 33262038 PMCID: PMC7654292 DOI: 10.1053/j.jvca.2020.11.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Tong Li
- Department of Intensive Care Unit, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peng-Fei Yin
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ang Li
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Yong-Xing Yao
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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38
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Hoyler MM, Flynn B, Iannacone EM, Jones MM, Ivascu NS. Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:2776-2792. [DOI: 10.1053/j.jvca.2019.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/04/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022]
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Singh SK, D'Ovidio F, Garan AR, Brodie D, Sonett JR, Farr MA, Arcasoy SM, Takeda K. Minimally invasive central venoarterial extracorporeal membrane oxygenation for long-term ambulatory support as a bridge to heart-lung transplant. J Artif Organs 2020; 23:394-396. [PMID: 32803543 DOI: 10.1007/s10047-020-01198-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/08/2020] [Indexed: 11/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming a key tool for bridge to heart, lung, or heart-lung transplantation, and ambulatory ECMO support offers many advantages to prepare the patients. We here present a case of successful en bloc heart and lung transplantation after long-term ambulatory support with a minimally invasive central venoarterial ECMO approach as bridge to transplant.
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Affiliation(s)
- Sameer K Singh
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, 177 Fort Washington Avenue, New York, US, 10032.
| | - Frank D'Ovidio
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, 177 Fort Washington Avenue, New York, US, 10032
| | - A Reshad Garan
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, US
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, US
| | - Joshua R Sonett
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, 177 Fort Washington Avenue, New York, US, 10032
| | - Maryjane A Farr
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, US
| | - Selim M Arcasoy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, US
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, 177 Fort Washington Avenue, New York, US, 10032
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Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396:199-212. [PMID: 32682486 DOI: 10.1016/s0140-6736(20)31047-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Höpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Höpitaux de Paris, Institut de Cardiologie, Paris, France.
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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Salna M, Abrams D, Brodie D. Physical rehabilitation in the awake patient receiving extracorporeal circulatory or gas exchange support. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:834. [PMID: 32793679 PMCID: PMC7396238 DOI: 10.21037/atm.2020.03.151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intensive care unit (ICU)-acquired weakness is a common and serious sequela of critical illness. There is a growing body of evidence supporting the use of early mobilization in the ICU to mitigate this adverse effect. Recent data suggest that such a strategy may be feasible in patients with the most severe forms of cardiopulmonary failure—those requiring temporary mechanical circulatory support (TCS) or extracorporeal life support (ECLS). Both the modality of mechanical support and patient-specific characteristics must be taken into consideration when determining the appropriateness of an early mobilization strategy. The purpose of this review is to explore the current understanding of and evidence for mobilization and rehabilitation of patients receiving TCS or ECLS, including the identification of factors that may predict greater success for early mobilization and potential risks and contraindications to active physical therapy. While it is not yet known which of these patients are most likely to benefit from physical rehabilitation, a common theme is the importance of an interprofessional team approach to ensure patient safety and maximize the likelihood of successful mobilization.
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Affiliation(s)
- Michael Salna
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, NY, USA
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Broman LM, Westlund CJ, Gilbers M, Perry da Câmara L, Prahl Wittberg L, Taccone FS, Malfertheiner MV, Di Nardo M, Swol J, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Belliato M, Lorusso R. Pressure and flow properties of dual-lumen cannulae for extracorporeal membrane oxygenation. Perfusion 2020; 35:736-744. [PMID: 32500818 DOI: 10.1177/0267659120926009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support; thus, guidance for proper cannulae size is required. Pressure-flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water. METHODS We performed a study evaluating pressure-flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer's corresponding curves obtained from the public domain. RESULTS The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain same drainage flow (hematocrit of 26%) compared with manufacturer's water charts in 13-31 Fr bi-caval dual-lumen cannulae. The same net difference was found in cavo-atrial cannulae (16-32 Fr), where a lower drainage pressure was required (Hct of 26%) compared with the manufacturer's test using blood with an Hct of 33%. Return pressure-flow data were similar, independent whether pumping blood or water, to the data reported by manufacturers. CONCLUSION Non-standardized testing of pressure-flow properties of extracorporeal membrane oxygenation dual-lumen cannulae prevents an adequate prediction of pressure-flow results when these cannulae are used in patients. Properties of dual-lumen cannulae may vary between sizes within same cannula family, in particular concerning the drainage flow.
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Affiliation(s)
- Lars Mikael Broman
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - C Jerker Westlund
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Martijn Gilbers
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Lisa Prahl Wittberg
- The Linné Flow Centre and BioMEx Centre, Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Fabio Silvio Taccone
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Maximilian V Malfertheiner
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany
| | - Matteo Di Nardo
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Justyna Swol
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Leen Vercaemst
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Perfusion, University Hospital Gasthuisberg, Louvain, Belgium
| | - Nicholas A Barrett
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College, London, UK
| | - Federico Pappalardo
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Belohlavek
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Mirko Belliato
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Lorusso
- Workgroup on Innovation and Technology in ECLS, EuroELSO, Newcastle upon Tyne, UK
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
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Roumy A, Liaudet L, Rusca M, Marcucci C, Kirsch M. Pulmonary complications associated with veno-arterial extra-corporeal membrane oxygenation: a comprehensive review. Crit Care 2020; 24:212. [PMID: 32393326 PMCID: PMC7216520 DOI: 10.1186/s13054-020-02937-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/30/2020] [Indexed: 01/07/2023] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving technology that provides transient respiratory and circulatory support for patients with profound cardiogenic shock or refractory cardiac arrest. Among its potential complications, VA-ECMO may adversely affect lung function through various pathophysiological mechanisms. The interaction of blood components with the biomaterials of the extracorporeal membrane elicits a systemic inflammatory response which may increase pulmonary vascular permeability and promote the sequestration of polymorphonuclear neutrophils within the lung parenchyma. Also, VA-ECMO increases the afterload of the left ventricle (LV) through reverse flow within the thoracic aorta, resulting in increased LV filling pressure and pulmonary congestion. Furthermore, VA-ECMO may result in long-standing pulmonary hypoxia, due to partial shunting of the pulmonary circulation and to reduced pulsatile blood flow within the bronchial circulation. Ultimately, these different abnormalities may result in a state of persisting lung inflammation and fibrotic changes with concomitant functional impairment, which may compromise weaning from VA-ECMO and could possibly result in long-term lung dysfunction. This review presents the mechanisms of lung damage and dysfunction under VA-ECMO and discusses potential strategies to prevent and treat such alterations.
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Affiliation(s)
- Aurélien Roumy
- Department of Cardiovascular Surgery, University Hospital, Lausanne, Switzerland.
| | - Lucas Liaudet
- Department of Intensive Care Medicine, University Hospital, Lausanne, Switzerland
| | - Marco Rusca
- Department of Intensive Care Medicine, University Hospital, Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, University Hospital, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Cardiovascular Surgery, University Hospital, Lausanne, Switzerland
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Riebandt J, Hanke JS. Der Herzinsuffizienzchirurg – Hausarzt und Herzchirurg. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-019-00350-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ZusammenfassungBei der Therapie der terminalen Herzinsuffizienz handelt es sich um einen Wachstumsmarkt – sowohl für Kardiologen als auch für Herzchirurgen. Der besondere Reiz der Arbeit eines Herzinsuffizienzchirurgen besteht in der notwendigen Multidisziplinarität und der Tatsache, dass es nicht nur um den rein mechanistischen Zugang im Sinne der chirurgischen Therapie geht. Vielmehr macht ein Großteil der Arbeit die Vor- und Nachbehandlung aus, die meist durch den Chirurgen selbst ausgeführt wird. Umfassende herzchirurgische Kenntnisse sind ebenso unumgänglich wie das Verständnis kardiologischer und intensivmedizinischer Therapiekonzepte, um dem Patienten eine individuelle und sinnvolle Therapie anbieten zu können. Der vorliegende Beitrag bietet interessierten Kollegen einen Überblick über die Möglichkeiten und Anforderungen in diesem Teilgebiet der Herzchirurgie.
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Keller SP. Contemporary approaches in the use of extracorporeal membrane oxygenation to support patients waiting for lung transplantation. Ann Cardiothorac Surg 2020; 9:29-41. [PMID: 32175237 DOI: 10.21037/acs.2019.12.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The introduction of the lung allocation score in 2005 prioritized patients with decreased transplant-free survival as the recipients of donor organs and effectively increased the number of critically-ill patients with end-stage lung disease waiting for transplantation. This change presented transplant programs with the challenge of how to both extend the lives of critically-ill, end-stage lung disease patients waiting for donor organs and maintain patient vitality to survival through the rigors of surgery and post-transplant recovery. Motivated by the dismal outcomes of patients maintained on mechanical ventilation pre-transplant, transplant centers increasingly deploy extracorporeal membrane oxygenation (ECMO) as a means of supporting patients with advanced disease as a bridge to successful lung transplantation. ECMO is an extracorporeal gas exchange device providing delivery of oxygen and removal of carbon dioxide from blood passed through the circuit. The specific cannulation strategy determines whether ECMO provides primarily respiratory or circulatory support. The cannulation approach is tailored to the specific physiological manifestations of the pre-lung transplant candidate's disease process. For patients with profound hypoxic respiratory failure, a cannulation strategy that captures a large fraction of the venous return is required to maintain adequate support whereas lower circuit flows are sufficient for patients with predominantly hypercapnic respiratory failure. Improving outcomes and increasing experience with ECMO is motivating transplant centers to initiate support before patients require mechanical ventilation. Awake cannulation is increasingly common and is used to avoid the complications associated with intubation in advanced lung failure. Determining criteria for initiation of support and identifying the optimal approach to support patients with right heart failure in need of circulatory support are avenues of active investigation. Use of ECMO and other forms of extracorporeal support are rapidly becoming a mainstay in the care of the pre-lung transplant patient with advanced disease.
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Affiliation(s)
- Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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ECLS-associated infections in adults: what we know and what we don't yet know. Intensive Care Med 2019; 46:182-191. [PMID: 31768569 PMCID: PMC7222121 DOI: 10.1007/s00134-019-05847-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/30/2019] [Indexed: 01/17/2023]
Abstract
Extracorporeal life support (ECLS) is increasingly used in the management of patients with severe cardiopulmonary disease. Infections are frequently the etiologies underlying the respiratory, and occasionally cardiac, failure that necessitates ECLS. Just as importantly, infections are among the most commonly reported adverse events during ECLS. Infections in this setting may be the sequelae of prolonged critical illness or of underlying immune dysregulation; they may be hospital-acquired infections, and they may or may not be attributable to the presence of ECLS itself, the latter being an aspect that can be difficult to determine. Current registry data and evidence from the literature offer some insights, but also leave open many questions regarding the nature and significance of infections reported both before and during ECLS, including the question of any causal link between ECLS and the development of infections. An ongoing lack of consistency in the identification, diagnosis, management, and prevention of infections during ECLS is limiting our ability to interpret literature data and thus highlighting the need for more rigorous investigation and standardization of definitions. This review aims to characterize the current understanding of infections associated with the use of ECLS, taking into account data from the updated Extracorporeal Life Support Organization Registry, which provides important context for understanding the epidemiology and outcomes of these patients.
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