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Bluth T, Güldner A, Spieth PM. [Ventilation concepts under extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS)]. DIE ANAESTHESIOLOGIE 2024; 73:352-362. [PMID: 38625538 DOI: 10.1007/s00101-024-01407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.
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Affiliation(s)
- Thomas Bluth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Andreas Güldner
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [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: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
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El Hennawy HM, Safar O, Thamer A, Asiri A, Abdullah HS, Alhadi WA, Al Faifi IS, Zaitoun MF, Asiri M, Al Faifi AS. Knowledge, Attitude, and Barriers Toward Deceased Organ Donation Among Health Care Professionals and Medical Students in Southern Saudi Arabia: A Cross-Sectional Study. EXP CLIN TRANSPLANT 2023; 21:772-778. [PMID: 37885294 DOI: 10.6002/ect.2023.0166] [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: 10/28/2023]
Abstract
OBJECTIVES Knowledge and attitude of health care professionals and medical students are crucial to promoting positive outcomes of organ donation. This study aimed to evaluate knowledge and attitudes of health care professionals and medical students on organ donation in Southern Saudi Arabia. MATERIALS AND METHODS We conducted a cross-sectional study of consented tertiary hospital health care professionals (n = 200) (group A) and medical students (n = 200) (group B) in Southern Saudi Arabia from December 2022 to April 2023. Anonymous questionnaires in aGoogle form were sentto participants via WhatsApp. The study questionnaire consisted of 3 sections: sociodemographic information, knowledge toward organ donation, and attitude toward organ donation. RESULTS Both groups had adequate knowledge on organ donation and brain death concepts, but this knowledge was not reflected in willingness to donate among the groups. Among people surveyed, 65% of group A and 45% of group B (P < .001) noted willingness to donate their organs, even to relatives. However, only 22% of group A and 14% of group B were registered as donors. The most common reasons for refusal in both groups were lack of knowledge about donation, fear of body disfigurement after death, and religious factor. Among the health care professionals (group A), although consultants knew more about the donation process, residents had more positive attitudes and motivation for donation. For groups A and B, the primary sources of information were the internet and social media. CONCLUSIONS Attitudes of medical students and health care personnel toward organ donation were positive, although they were generally reluctantto donate their organs. This study repeats the need for education interventions that should stress the importance of donation, brain death irreversibility, national legal regulations for organ donation, the compatibility of organ donation with religious values, and the explanation of inaccurate beliefs.
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Affiliation(s)
- Hany M El Hennawy
- From the Surgery Department, Section of Transplantation, Armed Forces Hospitals Southern Region, Kingdom of Saudi Arabia
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Cassara CM, Long MT, Dollerschell JT, Chae F, Hall DJ, Demiralp G, Stampfl MJ, Bernardoni B, McCarthy DP, Glazer JM. Extracorporeal Cardiopulmonary Resuscitation: A Narrative Review and Establishment of a Sustainable Program. Medicina (B Aires) 2022; 58:medicina58121815. [PMID: 36557017 PMCID: PMC9781756 DOI: 10.3390/medicina58121815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The rates of survival with functional recovery for out of hospital cardiac arrest remain unacceptably low. Extracorporeal cardiopulmonary resuscitation (ECPR) quickly resolves the low-flow state of conventional cardiopulmonary resuscitation (CCPR) providing valuable perfusion to end organs. Observational studies have shown an association with the use of ECPR and improved survivability. Two recent randomized controlled studies have demonstrated improved survival with functional neurologic recovery when compared to CCPR. Substantial resources and coordination amongst different specialties and departments are crucial for the successful implementation of ECPR. Standardized protocols, simulation based training, and constant communication are invaluable to the sustainability of a program. Currently there is no standardized protocol for the post-cannulation management of these ECPR patients and, ideally, upcoming studies should aim to evaluate these protocols.
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Affiliation(s)
- Chris M. Cassara
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-8100
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - John T. Dollerschell
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Floria Chae
- Department of Anesthesiology, Ohio State University Wexner Medical Center, 370 W. 9th Ave., Columbus, OH 43210, USA
| | - David J. Hall
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Matthew J. Stampfl
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Brittney Bernardoni
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Daniel P. McCarthy
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Joshua M. Glazer
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
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Büyükçoban S, Gençpınar T, Bayrak S, Bilen Ç, Akkaya G, Hancı V. An Assessment of the 100 Most Frequently Cited Articles Regarding Extracorporeal Membrane Oxygenation in the Literature. CYPRUS JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4274/cjms.2021.2675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Worku ET, Yeung F, Anstey C, Shekar K. The impact of reduction in intensity of mechanical ventilation upon venovenous ECMO initiation on radiographically assessed lung edema scores: A retrospective observational study. Front Med (Lausanne) 2022; 9:1005192. [PMID: 36203770 PMCID: PMC9531725 DOI: 10.3389/fmed.2022.1005192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients with severe acute respiratory distress syndrome (ARDS) typically receive ultra-protective ventilation after extracorporeal membrane oxygenation (ECMO) is initiated. While the benefit of ECMO appears to derive from supporting “lung rest”, reductions in the intensity of mechanical ventilation, principally tidal volume limitation, may manifest radiologically. This study evaluated the relative changes in radiographic assessment of lung edema (RALE) score upon venovenous ECMO initiation in patients with severe ARDS. Methods Digital chest x-rays (CXR) performed at baseline immediately before initiation of ECMO, and at intervals post (median 1.1, 2.1, and 9.6 days) were reviewed in 39 Adult ARDS patients. One hundred fifty-six digital images were scored by two independent, blinded radiologists according to the RALE (Radiographic Assessment of Lung Edema) scoring criteria. Ventilatory data, ECMO parameters and fluid balance were recorded at corresponding time points. Multivariable analysis was performed analyzing the change in RALE score over time relative to baseline. Results The RALE score demonstrated excellent inter-rater agreement in this novel application in an ECMO cohort. Mean RALE scores increased from 28 (22–37) at baseline to 35 (26–42) (p < 0.001) on D1 of ECMO; increasing RALE was associated with higher baseline APACHE III scores [ß value +0.19 (0.08, 0.30) p = 0.001], and greater reductions in tidal volume [ß value −2.08 (−3.07, −1.10) p < 0.001] after ECMO initiation. Duration of mechanical ventilation, and ECMO support did not differ between survivors and non-survivors. Conclusions The magnitude of reductions in delivered tidal volumes correlated with increasing RALE scores (radiographic worsening) in ARDS patients receiving ECMO. Implications for patient centered outcomes remain unclear. There is a need to define appropriate ventilator settings on venovenous ECMO, counterbalancing the risks vs. benefits of optimal “lung rest” against potential atelectrauma.
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Affiliation(s)
- Elliott T. Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- *Correspondence: Elliott T. Worku
| | - Francis Yeung
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Chris Anstey
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Medicine, Griffith University, Sunshine Coast Campus, Birtinya, QLD, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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7
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Mor Conejo M, Guitart Pardellans C, Fresán Ruiz E, Penela Sánchez D, Cambra Lasaosa FJ, Jordan Garcia I, Balaguer Gargallo M, Pons-Òdena M. Lung Recruitment Maneuvers Assessment by Bedside Lung Ultrasound in Pediatric Acute Respiratory Distress Syndrome. CHILDREN 2022; 9:children9060789. [PMID: 35740726 PMCID: PMC9222064 DOI: 10.3390/children9060789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 11/16/2022]
Abstract
The use of recruitment maneuvers (RMs) is suggested to improve severe oxygenation failure in patients with acute respiratory distress syndrome (ARDS). Lung ultrasound (LUS) is a non-invasive, safe, and easily repeatable tool. It could be used to monitor the lung recruitment process in real-time. This paper aims to evaluate bedside LUS for assessing PEEP-induced pulmonary reaeration during RMs in pediatric patients. A case of a child with severe ARDS due to Haemophilus influenzae infection is presented. Due to his poor clinical, laboratory, and radiological evolution, he was placed on venovenous extracorporeal membrane oxygenation (ECMO). Despite all measures, severe pulmonary collapse prevented proper improvement. Thus, RMs were indicated, and bedside LUS was successfully used for monitoring and assessing lung recruitment. The initial lung evaluation before the maneuver showed a tissue pattern characterized by a severe loss of lung aeration with dynamic air bronchograms and multiple coalescent B-lines. While raising a PEEP of 30 mmH2O, LUS showed the presence of A-lines, which was considered a predictor of reaeration in response to the recruitment maneuver. The LUS pattern could be used to assess modifications in the lung aeration, evaluate the effectiveness of RMs, and prevent lung overdistension.
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Affiliation(s)
- Mireia Mor Conejo
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
| | - Carmina Guitart Pardellans
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Elena Fresán Ruiz
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Daniel Penela Sánchez
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
| | - Francisco José Cambra Lasaosa
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Iolanda Jordan Garcia
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, 08950 Barcelona, Spain
- Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, CIBERESP, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Mònica Balaguer Gargallo
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, 08950 Barcelona, Spain
- Correspondence: (M.B.G.); (M.P.-Ò.)
| | - Martí Pons-Òdena
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain; (M.M.C.); (C.G.P.); (E.F.R.); (D.P.S.); (F.J.C.L.); (I.J.G.)
- Immune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, 08950 Barcelona, Spain
- Correspondence: (M.B.G.); (M.P.-Ò.)
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8
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Wang L, Shi Z, Chen W, Du X, Zhan L. Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome Caused by Chlamydia psittaci: A Case Report and Review of the Literature. Front Med (Lausanne) 2021; 8:731047. [PMID: 34722571 PMCID: PMC8554049 DOI: 10.3389/fmed.2021.731047] [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: 06/26/2021] [Accepted: 09/14/2021] [Indexed: 01/19/2023] Open
Abstract
Background: Infection of Chlamydia psittaci (C. psittaci) could lead to serious clinical manifestations in humans, including severe pneumonia with rapid progression, adult respiratory distress syndrome (ARDS), sepsis, multiple organ dysfunction syndromes (MODS), and probably death. Implementation of extracorporeal membrane oxygenation (ECMO) in the patient with severe ARDS gives a promising new method for recovery. Case Presentation: We report our successful use of venovenous (VV) ECMO in a 48-year-old man who manifested with severe respiratory distress syndrome, acute kidney injury, and septic shock caused by a diagnosis of pneumonia. After the combination of therapy including anti-infection, mechanical ventilation, and continuous renal replacement therapy (CRRT), acute inflammatory syndrome developed. However, his respiratory status rapidly deteriorated. Then, venoarterial (VA)-ECMO support was placed on the patient as suddenly slowing of the heart rate. Harlequin (North-South) syndrome occurred after ECMO initiation. A series of the process could not relieve hypoxia in the upper body. At last, transition to VV-ECMO improved hypoxia. The duration of VV-ECMO was 7 days and the mechanical ventilation was weaned on the next day. On the day of ECMO weaning, nanopore targeted sequencing (NTS) of bronchoalveolar lavage fluid (BALF) reported the presence of C. psittaci. After 19 days of critical systemic rehabilitation and combination therapy, the patient fully recovered from C. psittaci. Conclusion: This is the first reported case of the patient receiving ECMO for C. psittaci pneumonia. ECMO puts the lungs on temporary rest, promotes the recovery of pulmonary function, and also wins time for finding the pathogens, which is crucial in the treatment of rare pathogens.
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Affiliation(s)
- Lu Wang
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhaokun Shi
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wei Chen
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xianjin Du
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liying Zhan
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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Kleinloog D, Maas J, Lopez Matta J, Elzo Kraemer C. Favourable outcome after prolonged veno-venous extracorporeal membrane oxygenation (V-V ECMO) support for Pneumocystis jirovecii pneumonia in a renal transplant recipient. BMJ Case Rep 2021; 14:14/4/e240004. [PMID: 33795271 DOI: 10.1136/bcr-2020-240004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old man, with a history of renal transplantation, presented with acute kidney failure and Pneumocystis jirovecii pneumonia. The patient developed severe acute respiratory failure and required support by veno-venous extracorporeal membrane oxygenation for a total of 59 days. During this period, the patient had extremely low tidal volumes using a lung protective ventilation strategy and intermittent prone positioning was used to optimise oxygenation. There was full recovery of pulmonary and partial recovery of renal function.
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Affiliation(s)
- Daniel Kleinloog
- Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacinta Maas
- Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jorge Lopez Matta
- Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Carlos Elzo Kraemer
- Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
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11
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Falk L, Fletcher-Sandersjöö A, Hultman J, Broman LM. Conversion from Venovenous to Venoarterial Extracorporeal Membrane Oxygenation in Adults. MEMBRANES 2021; 11:membranes11030188. [PMID: 33803411 PMCID: PMC7999389 DOI: 10.3390/membranes11030188] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/13/2022]
Abstract
No major study has been performed on the conversion from venovenous (VV) to venoarterial (VA) extracorporeal membrane oxygenation (ECMO) in adults. This single-center retrospective cohort study aimed to investigate the incidence, indication, and outcome in patients who converted from VV to VA ECMO. All adult patients (≥18 years) who commenced VV ECMO at our center between 2005 and 2018 were screened. Of 219 VV ECMO patients, 21% (n = 46) were converted to VA ECMO. The indications for conversion were right ventricular failure (RVF) (65%), cardiogenic shock (26%), and other (9%). In the converted patients, there was a significant increase in Sequential Organ Failure Assessment (SOFA) scores between admission 12 (9-13) and conversion 15 (13-17, p < 0.001). Compared to non-converted patients, converted patients also had a higher mortality rate (62% vs. 16%, p < 0.001) and a lower admission Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score (p < 0.001). Outcomes were especially unfavorable in those converted due to RVF. These results indicate that VA ECMO, as opposed to VV ECMO, should be considered as the first mode of choice in patients with respiratory failure and signs of circulatory impairment, especially in those with impaired RV function. For the remaining patients, Pre-admission RESP score, daily echocardiography, and SOFA score trajectories may help in the early identification of those where conversion from VV to VA ECMO is warranted. Multi-centric studies are warranted to validate these findings.
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Affiliation(s)
- Lars Falk
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-51774040; Fax: +46-8-51778060
| | - Alexander Fletcher-Sandersjöö
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76 Stockholm, Sweden;
- Department of Neurosurgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Jan Hultman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17176 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
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12
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Belliato M, Epis F, Cremascoli L, Ferrari F, Quattrone MG, Fisser C, Malfertheiner MV, Taccone FS, Di Nardo M, Broman LM, Lorusso R. Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study. MEMBRANES 2021; 11:membranes11010030. [PMID: 33401668 PMCID: PMC7824596 DOI: 10.3390/membranes11010030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022]
Abstract
Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, p < 0.001), plateau pressure (27 vs. 21 cmH2O, p = 0.012), driving pressure (11 vs. 8 cmH2O, p = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, p < 0.001), and tidal volume adjusted to patient ideal body weight (VT/IBW, 5.5 vs. 4.0 mL/kg, p = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, p = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmH2O, p = 0.048) and VT/IBW (3.0 vs. 4.0 mL/kg, p = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.
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Affiliation(s)
- Mirko Belliato
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- Correspondence: ; Tel.: +39-0382-503524
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Fiorenza Ferrari
- 1st Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, 36100 Vicenza, Italy
| | - Maria Giovanna Quattrone
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Christoph Fisser
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Maximilian Valentin Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Brussels, 1070 Brussels, Belgium;
| | - Matteo Di Nardo
- Pediatric Intensive Care, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, and Department of Physiology and Pharmacology, Karolinska Institutet, 171 64 Solna (Stockholm), Sweden;
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
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13
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Colasanti S, Piemonte V, Devolder E, Zieliński K, Vandendriessche K, Meyns B, Fresiello L. Development of a computational simulator of the extracorporeal membrane oxygenation and its validation with in vitro measurements. Artif Organs 2020; 45:399-410. [PMID: 33034071 DOI: 10.1111/aor.13842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 12/20/2022]
Abstract
In the recent years, the use of extracorporeal membrane oxygenation (ECMO) has grown substantially, posing the need of having specialized medical and paramedical personnel dedicated to it. Optimization of the therapy, definition of new therapeutic strategies, and ECMO interaction with the cardiorespiratory system require numerous specific skills and preclinical models for patient successful management. The aim of the present work is to develop and validate a computational model of ECMO and connect it to an already existing lumped parameter model of the cardiorespiratory system. The ECMO model was connected between the right atrium and the aorta of the cardiorespiratory simulator. It includes a hydraulic module that is a representation of the tubing, oxygenator, and pump. The resulting pressures and flows within the ECMO circuit were compared to the measurements conducted in vitro on a real ECMO. Additionally, the hemodynamic effects the ECMO model elicited on the cardiorespiratory simulator were compared with experimental data taken from the literature. The comparison between the hydraulic module and the in vitro measurements evidenced a good agreement in terms of flow, pressure drops across the pump, across the oxygenator and the tubing (maximal percentage error recorded was 17.6%). The hemodynamic effects of the ECMO model on the cardiovascular system were in agreement with what observed experimentally in terms of cardiac output, systemic pressure, pulmonary arterial pressure, and left atrial pressure. The ECMO model we developed and embedded into the cardiorespiratory simulator, is a useful tool for the investigation of basic physiological mechanisms and principles of ECMO therapy. The model was sided by a user interface dedicated to training applications. As such, the resulting simulator can be used for the education of students, medical and paramedical personnel.
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Affiliation(s)
- Simona Colasanti
- Faculty of Engineering, University Campus Bio-Medico of Rome, Rome, Italy
| | - Vincenzo Piemonte
- Faculty of Engineering, University Campus Bio-Medico of Rome, Rome, Italy
| | - Emmanuel Devolder
- Department of Perfusion, University Hospitals of Leuven, Leuven, Belgium
| | - Krzysztof Zieliński
- Nałęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warszawa, Poland
| | - Katrien Vandendriessche
- Department of Cardiovascular Science, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiovascular Science, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Libera Fresiello
- Department of Cardiovascular Science, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium.,Institute of Clinical Physiology, National Research Council, Pisa, Italy
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14
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Extracorporeal support to achieve lung-protective and diaphragm-protective ventilation. Curr Opin Crit Care 2020; 26:66-72. [PMID: 31876625 DOI: 10.1097/mcc.0000000000000686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring. RECENT FINDINGS A recent randomized trial comparing the efficacy of extracorporeal support as a rescue therapy to conventional protective mechanical ventilation was stopped for futility but post hoc analyses suggested that extracorporeal support is beneficial for patients with very severe acute respiratory distress syndrome. However, the optimal ventilation settings during extracorporeal support are still debated. It is conceivable that they should enable the highest amount of CO2 removal with lowest mechanical power.Extracorporeal CO2 removal can minimize acidosis and enable the use of ultra-protective lung ventilation strategies when hypoxemia is not a major issue. Moreover, it can protect lung and diaphragm function during assisted ventilation through control of the respiratory effort.Lung mechanics, gas exchange, diaphragm electrical activity, ultrasound, electrical impedance tomography could be integrated into clinical management to define lung and diaphragm protection and guide personalized ventilation settings. SUMMARY Technological improvement and the latest evidence indicate that extracorporeal support may be an effective tool for lung and diaphragm protection.
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15
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Ventilatory management of patients on ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:248-253. [PMID: 33967448 PMCID: PMC8062618 DOI: 10.1007/s12055-020-01021-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 01/09/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is the final treatment offered to patients of acute respiratory distress syndrome (ARDS). The survival (to discharge) of patients on veno-venous ECMO is approximately 59% with an average duration of 8 days. The ventilatory management of lungs during the ECMO may have an impact on mortality. An ideal ventilation modality should promote recovery, prevent further damage to the alveoli, and enable weaning from mechanical ventilation. This article reviews the concept of “baby lung” in ARDS and the current evidence for the use of lung protective ventilation, prevention of ventilator-induced lung injury, recommended modes of mechanical ventilation, ideal ventilatory parameters (tidal volume, positive end expiratory pressure, plateau pressure, respiratory rate, fractional inspired oxygen concentration), and use of adjuncts (prone positioning, neuromuscular blocking agents) during the ECMO course.
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16
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Yin C, Gao X, Cao C, Xu L, Lu X. Individualized positive end-expiratory pressure setting in patients with severe acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation. Perfusion 2020; 36:374-381. [PMID: 32777988 DOI: 10.1177/0267659120946728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation benefit from higher positive end-expiratory pressure combined with conventional ventilation during the early extracorporeal membrane oxygenation period. The role of incremental positive end-expiratory pressure titration in patients with severe acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation remains unclear. This study aimed to determine the preferred method for setting positive end-expiratory pressure in patients with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation support. METHODS We retrospectively reviewed all subjects supported with veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from 2009 to 2019 in the intensive care units in Tianjin Third Central Hospital. Subjects were divided into two groups according to the positive end-expiratory pressure titration method used: P-V curve (quasi-static pressure-volume curve-guided positive end-expiratory pressure setting) group or Crs (respiratory system compliance-guided positive end-expiratory pressure setting) group. RESULTS Forty-three subjects were included in the clinical outcome analysis: 20 in the P-V curve group and 23 in the Crs group. Initial positive end-expiratory pressure levels during veno-venous extracorporeal membrane oxygenation were similar in both groups. Incidence rates of barotrauma and hemodynamic events were significantly lower in the Crs group (all p < 0.05). Mechanical ventilation duration, intensive care unit length of stay, and hospital length of stay were significantly shorter in the Crs group than the P-V curve group (all p < 0.05). Subjects in the Crs group showed non-significant improvements in the duration of extracorporeal membrane oxygenation support and 28-day mortality (p > 0.05). CONCLUSION Respiratory system compliance-guided positive end-expiratory pressure setting may lead to more optimal clinical outcomes for patients with severe acute respiratory distress syndrome supported by veno-venous extracorporeal membrane oxygenation. Moreover, the operation is simple, safe, and convenient in clinical practice.
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Affiliation(s)
- Chengfen Yin
- Department of Critical Care Medicine, The Third Central Clinical College of Tianjin Medical University, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Third Central Hospital, Hedong District, Tianjin, China
| | - Xinjing Gao
- Tianjin Third Central Hospital, Hedong District, Tianjin, China
| | - Chao Cao
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Lei Xu
- Department of Critical Care Medicine, The Third Central Clinical College of Tianjin Medical University, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Third Central Hospital, Hedong District, Tianjin, China
| | - Xing Lu
- Department of Critical Care Medicine, The Third Central Clinical College of Tianjin Medical University, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Third Central Hospital, Hedong District, Tianjin, China
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Zochios V, Protopapas AD. Least damaging invasive ventilation during extracorporeal respiratory support after lung transplantation. Ann Cardiothorac Surg 2019; 8:516-517. [PMID: 31463219 DOI: 10.21037/acs.2019.05.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Vasileios Zochios
- Department of Critical Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
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