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Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
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Kahveci F, Coşkun MK, Uçmak H, Özen H, Gurbanov A, Balaban B, Dikmen N, Karagözlü S, Sarıcaoğlu MC, Botan E, Gün E, Havan M, Ramoğlu MG, Uçar T, Eyileten Z, Tutar E, Akar AR, Kendirli T. Hybrid extracorporeal membrane oxynegation in pediatric intensive care patients: A single center experience: More is better? Perfusion 2024; 39:902-910. [PMID: 37010553 DOI: 10.1177/02676591231168537] [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: 04/04/2023]
Abstract
BACKGROUND The initial extracorporeal membrane oxygenation (ECMO) configuration is inefficient for patient oxygenation and flow, but by adding a Y-connector, a third or fourth cannula can be used to support the system, which is called hybrid ECMO. METHODS This was a single-center retrospective study consisting of patients receiving hybrid and standard ECMO in our PICU between January 2014 and January 2022. RESULTS The median age of the 12 patients who received hybrid ECMO and were followed up with hybrid ECMO was 140 (range, 82-213) months. The total median ECMO duration of the patients who received hybrid ECMO was 23 (8-72) days, and the median follow-up time on hybrid ECMO was 18 (range, 3-46) days. The mean duration of follow-up in the PICU was 34 (range, 14-184) days. PICU length of stay was found to be statistically significant and was found to be longer in the hybrid ECMO group (p = 0.01). Eight (67%) patients died during follow-up with ECMO. Twenty-eight-day mortality was found to be statistically significant and was found to be higher in the standard ECMO group (p = 0.03). The hybrid ECMO mortality rate was 66% (decannulation from ECMO). The hybrid ECMO hospital mortality rate was 75%. The standard ECMO mortality rate was 52% (decannulation from ECMO). The standard ECMO hospital mortality rate was 65%. CONCLUSIONS Even though hybrid ECMO use is rare, with increasing experience and new methods, more successful experience will be gained. Switching to hybrid ECMO from standard ECMO at the right time with the right technique can increase treatment success and survival.
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Affiliation(s)
- Fevzi Kahveci
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mert Kaan Coşkun
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hasan Özen
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Anar Gurbanov
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Burak Balaban
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Nur Dikmen
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Selen Karagözlü
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Edin Botan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emrah Gün
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Merve Havan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Gökhan Ramoğlu
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tayfun Uçar
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Eyileten
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ercan Tutar
- Division of Pediatric Cardiology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Rüçhan Akar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
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Dave SB, Leiendecker E, Creel-Bulos C, Miller CF, Boorman DW, Javidfar J, Attia T, Daneshmand M, Jabaley CS, Caridi-Schieble M. Outcomes following additional drainage during veno-venous extracorporeal membrane oxygenation: A single-center retrospective study. Perfusion 2024:2676591241249609. [PMID: 38756070 DOI: 10.1177/02676591241249609] [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: 05/18/2024]
Abstract
Refractory hypoxemia during veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) may require an additional cannula (VV-V ECMO) to improve oxygenation. This intervention includes risk of recirculation and other various adverse events (AEs) such as injury to the lung, cannula malpositioning, bleeding, circuit or cannula thrombosis requiring intervention (i.e., clot), or cerebral injury. During the study period, 23 of 142 V-V ECMO patients were converted to VV-V utilizing two separate cannulas for bi-caval drainage with an additional upper extremity cannula placed for return. Of those, 21 had COVID-19. In the first 24 h after conversion, ECMO flow rates were higher (5.96 vs 5.24 L/min, p = .002) with no significant change in pump speed (3764 vs 3630 revolutions per minute [RPMs], p = .42). Arterial oxygenation (PaO2) increased (87 vs 64 mmHg, p < .0001) with comparable pre-oxygenator venous saturation (61 vs 53.3, p = .12). By day 5, flows were similar to pre-conversion values at lower pump speed but with improved PaO2. Unadjusted survival was similar in those converted to VV-V ECMO compared to V-V ECMO alone (70% [16/23] vs 66.4% [79/119], p = .77). In a mixed effect regression model, any incidence of AEs, demonstrated a negative impact on PaO2 in the first 48 h but not at day 5. VV-V ECMO improved oxygenation with increasing flows without a significant difference in AEs or pump speed. AEs transiently impacted oxygenation. VV-V ECMO is effective and feasible strategy for refractory hypoxemia on VV-ECMO allowing for higher flow rate and unchanged pump speed.
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Affiliation(s)
- Sagar B Dave
- Department of Emergency Medicine, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Eric Leiendecker
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Christina Creel-Bulos
- Department of Emergency Medicine, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Casey Frost Miller
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - David W Boorman
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey Javidfar
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Tamer Attia
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mani Daneshmand
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Craig S Jabaley
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Mark Caridi-Schieble
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
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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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Daughtry B, Richardson J. Case Report: Combined perioperative extracorporeal membrane oxygenation for acute heart failure caused by mitral regurgitation. Front Cardiovasc Med 2024; 11:1345654. [PMID: 38559673 PMCID: PMC10978710 DOI: 10.3389/fcvm.2024.1345654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) devices are well-established adjunctive treatment measures for patients with heart failure. ECMO can serve as a bridge to transplant in a chronic setting or as a salvage therapy for patients who are unable to be weaned from bypass following cardiac surgery. However, the role of ECMO as a bridge to definitive therapy in a setting of acute heart failure is less established. Similarly, the treatment of patients using combined ECMO and ECLS devices has been, at times, shown to show some benefit; however, these benefits have not been widely studied. In this study, we present the case of a patient who was diagnosed with severe acute onset heart failure secondary to torrential mitral regurgitation following COVID-19 pneumonia. The patient was emergently placed on venoarterial (VA) ECMO with an indwelling centrifugal pump device in the left ventricle. This combination of ECMO and ECLS served as a bridge to open mitral valve replacement 6 days after presentation. Following successful mitral valve replacement, the patient had persistent right ventricular failure, and therefore, a decision was made to incorporate venovenous (VV) ECMO into the VA ECMO circuit. This technique resulted in a VV-VA or VPa-VA configuration, as oxygenated blood was being returned to the pulmonary artery as well as the descending aorta. VA ECMO was discontinued after 4 days of therapy, and the patient was extubated 3 days later. VV ECMO was weaned over the following week, and the patient was decannulated after a total 23 days of ECMO. The patient was then transitioned to inpatient rehabilitation and ultimately discharged home after 18 days. At the 6-month follow-up, the patient was doing well, and objective cardiopulmonary testing revealed normal function. This case is an excellent demonstration of how advanced ECMO and ECLS devices can be used in unique ways through multiple configurations to rescue and optimize patients in the perioperative period.
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Affiliation(s)
- Brock Daughtry
- Department of Surgery, Brookwood Baptist Health, Birmingham, AL, United States
| | - John Richardson
- Department of Cardiothoracic Surgery, Grandview Medical Center, Birmingham, AL, United States
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Das S, Chakraborty U, Sarkar A, Saha A, Narayan P. Complex management of pulmonary embolism in APLA syndrome: a case study of ECMO and bivalirudin utilization. Indian J Thorac Cardiovasc Surg 2024; 40:254-258. [PMID: 38389757 PMCID: PMC10879040 DOI: 10.1007/s12055-023-01667-5] [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: 09/04/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 02/24/2024] Open
Abstract
We report a case of a 22-year-old female with antiphospholipid antibody (APLA) syndrome who presented with severe dyspnea. Diagnostic imaging confirmed pulmonary embolism (PE), and treatment comprised unfractionated heparin and apixaban. APLA syndrome was diagnosed based on clinical, serological, and radiological findings. During evaluation, the patient developed cardiogenic shock necessitating catheter-directed thrombolysis, followed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to deteriorating condition and suspected heparin-induced thrombocytopenia (HIT). Surgical embolectomy with bivalirudin use followed, and a hybrid veno-arterial-venous (VAV) ECMO setup was implemented. Postoperatively, the patient improved, transitioning to veno-venous (VV) ECMO and eventually ECMO withdrawal. ECMO is a valuable tool for managing complex cardiorespiratory cases like PE. In the context of HIT and APLA syndrome, prompt anticoagulant transition is vital, and bivalirudin is an effective heparin alternative. Our study highlights the challenges involved in managing patients needing ECMO support with immunothrombotic conditions like HIT and APLA syndrome.
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Affiliation(s)
- Somnath Das
- Department of Clinical Perfusion, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, Kolkata, India
| | - Unmesh Chakraborty
- Department of Cardiothoracic and Vascular Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Abhinaba Sarkar
- Department of Cardiothoracic and Vascular Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| | - Atanu Saha
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, Kolkata, India
| | - Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, Kolkata, India
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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Sahli SD, Kaserer A, Braun J, Aser R, Spahn DR, Wilhelm MJ. A Descriptive Analysis of Hybrid Cannulated Extracorporeal Life Support. J Pers Med 2024; 14:179. [PMID: 38392612 PMCID: PMC10889992 DOI: 10.3390/jpm14020179] [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: 12/13/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Extracorporeal life support (ECLS) is pivotal for sustaining the function of failing hearts and lungs, and its utilization has risen. In cases where conventional cannulation strategies prove ineffective for providing adequate ECLS support, the implementation of an enhanced system with a third cannula may become necessary. Hybrid ECLS may be warranted in situations characterized by severe hypoxemia of the upper extremity, left ventricular congestion, and dilatation. Additionally, it may also be considered for patients requiring respiratory support or experiencing hemodynamic instability. METHOD All hybrid ECLS cases of adults at the University Hospital Zurich, Switzerland, between January 2007 and December 2019 with initial triple cannulation were included. Data were collected via a retrospective review of patient records and direct export of the clinical information system. RESULTS 28 out of 903 ECLS cases were initially hybrid cannulated (3.1%). The median age was 57 (48.2 to 60.8) years, and the sex was equally distributed. The in-hospital mortality of hybrid ECLS was high (67.9%). In-hospital mortality rates differ depending on the indication (ARDS: 36.4%, refractory cardiogenic shock: 88.9%, cardiopulmonary resuscitation: 100%, post-cardiotomy: 100%, others: 75%). Survivors exhibited a lower SAPS II level compared with non-survivors (20.0 (12.0 to 65.0) vs. 55.0 (45.0 to 73.0)), and the allogenic transfusion of platelet concentrate was observed to be less frequent for survivors (0.0 (0.0) vs. 1.8 (2.5) units). CONCLUSION The in-hospital mortality rate for hybrid ECLS was high. Different indications showed varying mortality rates, with survivors having lower SAPS II scores and requiring fewer platelet concentrate transfusions. These findings highlight the complexities of hybrid ECLS outcomes in different clinical scenarios and underline the importance of rigorous patient selection.
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Affiliation(s)
- Sebastian D Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute, Departments of Epidemiology and Biostatistics, University of Zurich, 8057 Zurich, Switzerland
| | - Raed Aser
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Donat R Spahn
- Formerly, Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland
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Hockstein MA, Fan E. The Roles of Venopulmonary Arterial Extracorporeal Membrane Oxygenation. Crit Care Med 2024; 52:297-306. [PMID: 37909826 DOI: 10.1097/ccm.0000000000006094] [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: 11/03/2023]
Abstract
OBJECTIVES Concise definitive review of the use of venopulmonary arterial extracorporeal membrane oxygenation (V-PA ECMO) support in patients with cardiopulmonary failure. DATA SOURCES Original investigations identified through a PubMed search with search terms "percutaneous right ventricular assist device," "oxy-RVAD," "V-PA ECMO," and "veno-pulmonary arterial ECMO" were reviewed and evaluated for relevance. STUDY SELECTION Studies that included more than three patients supported with V-PA ECMO were included. DATA EXTRACTION Clinically relevant data from included studies, including patient-important outcomes, were summarized and discussed. DATA SYNTHESIS We identified four groups of patients where V-PA ECMO has been studied: acute respiratory distress syndrome, right ventricular dysfunction after left ventricular assist device placement, bridge to lung transplantation, and pulmonary embolism. Most identified works are small, single center, and retrospective in nature, precluding definitive conclusions regarding the efficacy of V-PA ECMO. There have been no clinical trials evaluating the efficacy of V-PA ECMO for any indication. CONCLUSIONS V-PA ECMO is a promising form of extracorporeal support for patients with right ventricular dysfunction. Future work should focus on identifying the optimal timing and populations for the use of V-PA ECMO.
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Affiliation(s)
- Maxwell A Hockstein
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Zaaqoq AM, Fraser JF. Naming and Unnaming in the Extracorporeal Membrane Oxygenation Literature. ASAIO J 2024; 70:e17. [PMID: 37643316 DOI: 10.1097/mat.0000000000002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, Virginia
| | - John F Fraser
- Critical care research group, Institute of molecular bioscience, University of Queensland, Brisbane, Queensland, Australia
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11
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Rozencwajg S, Wu EL, Heinsar S, Stevens M, Chinchilla J, Fraser JF, Pauls JP. A mock circulation loop to evaluate differential hypoxemia during peripheral venoarterial extracorporeal membrane oxygenation. Perfusion 2024; 39:66-75. [PMID: 35038287 DOI: 10.1177/02676591211056567] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) creates a retrograde flow along the aorta competing with the left ventricle (LV) in the so-called 'mixing zone' (MZ). Detecting it is essential to understand which of the LV or the ECMO flow perfuses the upper body - particularly the brain and the coronary arteries - in case of differential hypoxemia (DH). METHODS We described a mock circulation loop (MCL) that enabled experimental research on DH. We recreated the three clinical situations relevant to clinicians: where the brain is either totally perfused by the ECMO or the LV or both. In a second step, we used this model to investigate two scenarios to diagnose DH: (i) pulse pressure and (ii) thermodilution via injection of cold saline in the ECMO circuit. RESULTS The presented MCL was able to reproduce the three relevant mixing zones within the aortic arch, thus allowing to study DH. Pulse pressure was unable to detect location of the MZ. However, the thermodilution method was able to detect whether the brain was totally perfused by the ECMO or not. CONCLUSION We validated an in-vitro differential hypoxemia model of cardiogenic shock supported by VA ECMO. This MCL could be used as an alternative to animal studies for research scenarios.
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Affiliation(s)
- Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, Paris, France
| | - Eric L Wu
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - Michael Stevens
- Graduate School of Biomedical Engineering, UNSW Sydney, AU -NSW, Australia
| | - Josh Chinchilla
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, AU-QLD, Australia
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12
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Davies MG, Hart JP. Current status of ECMO for massive pulmonary embolism. Front Cardiovasc Med 2023; 10:1298686. [PMID: 38179509 PMCID: PMC10764581 DOI: 10.3389/fcvm.2023.1298686] [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: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G. Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
- Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX, United States
| | - Joseph P. Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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13
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Chico JI, Gomez V, Freita S, Rivas MD, Mosquera D, Menor EM, Piñon MA. Successful implementation of prophylactic veno-venoarterial extracorporeal membrane oxygenation in high-risk trauma surgery: A case report. Perfusion 2023:2676591231220832. [PMID: 38051548 DOI: 10.1177/02676591231220832] [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: 12/07/2023]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) is increasingly utilized in trauma care, yet its elective use during high-risk surgeries remains unreported. CASE REPORT We report a successful instance of prophylactic ECMO support via a Veno-Venoarterial (V-VA) configuration during high-risk surgery in a patient with extensive trauma, including severe thoracic damage and a highly unstable thoracic spine fracture. V-VA ECMO prevented complications such as hemodynamic and respiratory collapse associated with chest compression during the surgical procedure, as the patient should be in a prone position. DISCUSSION The potential of ECMO as prophylactic support in high-risk surgery amongst trauma patients underscores a novel application of this technology. Complex configurations must be evaluated to avoid associated ECMO complications. CONCLUSION Our case highlights the potential of prophylactic ECMO hybrid modes, indicating their safe application during high-risk procedures in select trauma patients.
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Affiliation(s)
- Juan I Chico
- Critical Care Department, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Vanesa Gomez
- Critical Care Department, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Santiago Freita
- Critical Care Department, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - María D Rivas
- Critical Care Department, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - David Mosquera
- Critical Care Department, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Eva M Menor
- Critical Care Department, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Miguel A Piñon
- Cardiothoracic Surgery Department, Alvaro Cunqueiro Hospital, Vigo, Spain
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14
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Lee Y, Jang I, Hong J, Son YJ. Factors associated with 30-day in-hospital mortality in critically ill adult patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Intensive Crit Care Nurs 2023; 79:103489. [PMID: 37451086 DOI: 10.1016/j.iccn.2023.103489] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To identify factors associated with the 30-day in-hospital mortality rate among adult patients requiring extracorporeal membrane oxygenation (ECMO) in intensive care units. RESEARCH METHODOLOGY Retrospective cohort study including 148 patients who underwent ECMO for at least 48 h between March 2010 and August 2021. The patients were divided into survivors and non-survivors based on their 30-day in-hospital survival. We obtained the sociodemographic information and pre- and post-ECMO data from electronic medical records. Kaplan-Meier survival curves and Multivariate Cox proportional hazards regression were used to analyse the data. SETTING A tertiary-care university hospital in South Korea. MAIN OUTCOME MEASURES The 30-day in-hospital mortality rate was the principal outcome measure. RESULTS The 30-day in-hospital mortality rate was 49.3% (n = 73). Kaplan-Meier analysis demonstrated that the duration of ECMO support in the 50th percentile of surviving patients was 13 days. Multivariable Cox regression analysis showed that new-onset renal failure, lower mean arterial pressure, and ECMO weaning failure were associated with an increased 30-day in-hospital mortality risk among patients who received ECMO. Subgroup analysis also revealed a significant association between weaning failure and 30-day in-hospital mortality after adjusting for covariates in patients undergoing veno-arterial ECMO. CONCLUSION Close monitoring of post-ECMO renal function and mean arterial pressure is required to minimize the risk of 30-day in-hospital mortality, especially in adults within the first two weeks of ECMO initiation. Moreover, the success of ECMO weaning should be optimized by collaboration within the ECMO team. IMPLICATIONS FOR CLINICAL PRACTICE Critical care nurses should pay close attention to patients' response to weaning trials as well as alternations in renal function and mean arterial pressure during ECMO support. Furthermore, developing nursing care guidelines for adult patients receiving ECMO and standardized training programs for nurses in intensive care, are required in Korea.
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Affiliation(s)
- Youngeon Lee
- Emergency Intensive Care Unit, Department of Nursing, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, South Korea.
| | - Insil Jang
- Red Cross College of Nursing, Chung-Ang University, 84 Heukseok ro, Dongjak-gu, Seoul 06974, South Korea.
| | - Joonhwa Hong
- Department of Thoracic and Cardiovascular Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 84 Heukseok ro, Dongjak-gu, Seoul 06974, South Korea.
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, 84 Heukseok ro, Dongjak-gu, Seoul 06974, South Korea.
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15
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Butt SP, Raposo N, Saleem Y. A multipurpose Extracorporeal Life Support Circuit: a concept for multiorgan transplant and circulatory support service Healthcare provider. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:218-220. [PMID: 38099639 PMCID: PMC10723577 DOI: 10.1051/ject/2023038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/05/2023] [Indexed: 12/18/2023]
Abstract
The demand for efficient and adaptable life support systems in the field of Extracorporeal Life Support (ECLS) is steadily increasing. To meet this growing need, there is a requirement for a versatile extracorporeal life support circuit that can be effectively applied in various medical scenarios, especially in tertiary hospitals where multiple ECLS services are utilized. These services include Extracorporeal Membrane Oxygenation (ECMO) for addressing respiratory or cardiac problems, Ventricular Assist Device (VAD) as a bridge to recovery or heart transplant, and Venovenous Bypass (VVB) for assisting liver transplantation. In light of this, we propose the creation of a multipurpose circuit that integrates multiple extracorporeal life support (ECLS) functions to cater to diverse medical needs. This innovative circuit not only offers cost-effectiveness and enhanced safety but also ensures optimal utilization, thereby revolutionizing the realm of life support technologies.
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Affiliation(s)
- Salman Pervaiz Butt
- Perfusionist & ECMO Specialist, Cleveland Clinic, Abu Dhabi, United Arab Emirates, Honorary Lecturer University of Bristol, AmSECT Membership No: 8270 PO Box: 112412 United Arab Emirates
| | - Nuno Raposo
- Perfusionist, Perfusion Department, Cleveland Clinic Abu Dhabi United Arab Emirates
| | - Yasir Saleem
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Clinical Perfusionist, Department of CTVS, All India Institute of Medical Science-Rishikesh
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16
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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17
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Nersesian G, Ott S, Fardman A, Lanmueller P, Lewin D, Bernhardt A, Emrich F, Faerber G, Szabó G, Oezkur M, Panholzer B, Rojas SV, Saeed D, Schmack B, Warnecke G, Zimpfer D, Grubitzsch H, Falk V, Potapov E. Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients after Cardiac Procedures: Selection Algorithm and Weaning Strategies. Life (Basel) 2023; 13:2045. [PMID: 37895427 PMCID: PMC10608612 DOI: 10.3390/life13102045] [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: 09/07/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Mechanical circulatory support has proven effective in managing postcardiotomy cardiogenic shock by stabilizing patients' hemodynamics and ensuring adequate organ perfusion. Among the available device modalities, the combination of extracorporeal life support and a microaxial flow pump for left ventricular unloading has emerged as a valuable tool in the surgical armamentarium. In this publication, we provide recommendations for the application and weaning of temporary mechanical circulatory support in cardiogenic shock patients, derived from a consensus among leading cardiac centers in German-speaking countries.
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Affiliation(s)
- Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Sascha Ott
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
| | - Alexander Fardman
- Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Pia Lanmueller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Daniel Lewin
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Alexander Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20251 Hamburg, Germany
| | - Fabian Emrich
- Department of Cardiac Surgery, Goethe University Hospital, 60590 Frankfurt, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07747 Jena, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, Middle German Heart Centre, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital Mainz, 55131 Mainz, Germany
| | - Bernd Panholzer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Sebastian V. Rojas
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, 32545 Bad Oeynhausen, Germany
| | - Diyar Saeed
- Department for Cardiac Surgery, Heart Center Niederrhein, 47805 Krefeld, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Daniel Zimpfer
- Department of Cardiothoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Herko Grubitzsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10178 Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10178 Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, 8092 Zurich, Switzerland
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
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18
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Li W, Chen C, Hu D, Sun F, Zhang G, Zhang Z, Dong Y, Lv J, Mei Y, Chen X. Randomized controlled trial of ultra-protective vs. protective ventilation strategy in veno-arterial extracorporeal membrane oxygenation patients with refractory cardiogenic shock: a study protocol for the ultra-ECMO trial. Front Cardiovasc Med 2023; 10:1092653. [PMID: 37215539 PMCID: PMC10196449 DOI: 10.3389/fcvm.2023.1092653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/30/2023] [Indexed: 05/24/2023] Open
Abstract
Background A protective or ultra-protective tidal volume strategy is widely applied to patients with acute respiratory distress syndrome (ARDS). The use of very low tidal volume has the potential to further redece ventilation-induced lung injury (VILI) comparde with a "normal" lung protective management. Plus, cardiogenic pulmonary edema (CPE) caused by hydrostatic mechanisms in patients with cardiogenic shock has similar respiratory mechanics to those found in patients with ARDS. And no consensus exists on mechanical ventilation parameter settings in patients with VA-ECMO. The study aimed to investigate the impact of an ultra-protective tidal volume strategy on the 28-day ventilator-free day (VFD) number in VA-ECMO-supported patients with refractory cardiogenic shock, including cardiac arrest. Methods The Ultra-ECMO trial is a randomized controlled, open-label, single-center prospective superiority trial. At the onset of ECMO initiation, we will divide patients randomly into an intervention group and a control group in a 1:1 ratio. The control group will adopt protective ventilation settings [initial tidal volume: 6 ml/kg of predicted body weight (PBW)] for ventilation, and the intervention group will adopt ultra-protective ventilation settings (initial tidal volume: 4 ml/kg of PBW) for ventilation. The procedure is expected to last 72 h, after which the ventilator settings will be at the intensivists' discretion. The primary outcome is the VFD number at 28 days after inclusion. The secondary outcomes will include respiratory mechanics; analgesic/sedation dosage; lung ultrasound score; interleukin-6, interleukin-8, and monocyte chemotactic protein-1 levels in broncho-alveolar lavage fluid at the moment of enrollment (T0), 24, 48, and 72 h (T1, T2, and T3, respectively) after ECMO initiation; total time (in days) required for ECMO weaning; length of stay in the intensive care unit; total cost of hospitalization; amounts of resuscitative fluids; and in-hospital mortality. Discussion VA-ECMO-treated patients without ARDS possess abnormal lung function. CPE, thoracic compliance reduction, and poor pulmonary blood perfusion are frequently present, and these patients can more easily progress to ARDS. It seems that targeting the protective tidal volume can lower adverse outcome incidence rates, even in patients without ARDS. This trial seeks to answer the question of whether adopting an ultra-protective tidal volume strategy can lead to superior primary and secondary outcomes compared to adopting a protective tidal volume strategy in patients treated by VA-ECMO. The Ultra-ECMO trial will provide an innovative mechanical ventilation strategy for VA-ECMO-supported patients for improving treatment outcomes at biological and potentially clinical levels. Clinical Trial Registration ChiCTR2200067118.
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Affiliation(s)
| | | | | | | | | | | | | | - Jinru Lv
- Correspondence: Jinru Lv Yong Mei Xufeng Chen
| | - Yong Mei
- Correspondence: Jinru Lv Yong Mei Xufeng Chen
| | - Xufeng Chen
- Correspondence: Jinru Lv Yong Mei Xufeng Chen
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19
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De Lazzari B, Capoccia M, Badagliacca R, Bozkurt S, De Lazzari C. IABP versus Impella Support in Cardiogenic Shock: “In Silico” Study. J Cardiovasc Dev Dis 2023; 10:jcdd10040140. [PMID: 37103019 DOI: 10.3390/jcdd10040140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/21/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Cardiogenic shock (CS) is part of a clinical syndrome consisting of acute left ventricular failure causing severe hypotension leading to inadequate organ and tissue perfusion. The most commonly used devices to support patients affected by CS are Intra-Aortic Balloon Pump (IABP), Impella 2.5 pump and Extracorporeal Membrane Oxygenation. The aim of this study is the comparison between Impella and IABP using CARDIOSIM© software simulator of the cardiovascular system. The results of the simulations included baseline conditions from a virtual patient in CS followed by IABP assistance in synchronised mode with different driving and vacuum pressures. Subsequently, the same baseline conditions were supported by the Impella 2.5 with different rotational speeds. The percentage variation with respect to baseline conditions was calculated for haemodynamic and energetic variables during IABP and Impella assistance. The Impella pump driven with a rotational speed of 50,000 rpm increased the total flow by 4.36% with a reduction in left ventricular end-diastolic volume (LVEDV) by ≅15% to ≅30%. A reduction in left ventricular end systolic volume (LVESV) by ≅10% to ≅18% (≅12% to ≅33%) was observed with IABP (Impella) assistance. The simulation outcome suggests that assistance with the Impella device leads to higher reduction in LVESV, LVEDV, left ventricular external work and left atrial pressure-volume loop area compared to IABP support.
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20
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Tantway TM, Arafat AA, Albabtain MA, Belghith M, Osman AA, Aboughanima MA, Abdullatif MT, Elshoura YA, AlBarak MM. Sepsis in postcardiotomy cardiogenic shock patients supported with veno- arterial extracorporeal membrane oxygenation. Int J Artif Organs 2023; 46:153-161. [PMID: 36744676 DOI: 10.1177/03913988231152978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sepsis could affect the outcomes of patients with postcardiotomy cardiogenic shock supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to characterize sepsis patients with ECMO support for postcardiotomy cardiogenic shock and assess its predictors and effect on patients' outcomes. METHODS This retrospective study included 103 patients with ECMO for postcardiotomy cardiogenic shock from 2009 to 2020. Patients were divided according to the occurrence and timing of sepsis into three groups. Group 1 included patients with no sepsis (n = 67), Group 2 included patients with ECMO-related sepsis (n = 10), and Group 3 included patients with non-ECMO-related sepsis (n = 26). RESULTS Lactate level before ECMO was highest in the ECMO-associated sepsis group (Group 1 and 2 p = 0.003 and Group 2 and 3 p = 0.003). Dialysis and gastrointestinal bleeding were highest in ECMO-associated sepsis (p = 0.03 and 0.04, respectively). Blood transfusion was higher in ECMO-associated sepsis than in patients with no sepsis (p = 0.01). Mortality was nonsignificantly higher in patients with ECMO-associated sepsis. High BMI (OR: 1.11; p = 0.004), preoperative dialysis (OR: 7.35; p = 0.02), preoperative IABP (OR: 9.9.61; p = 0.01) and CABG (OR: 6.29; p = 0.01) were significantly associated with sepsis. Older age (OR: 1.08; p = 0.004), lower BSA (OR: 0.004; p = 0.003), peripheral cannulation (OR: 29.82; p = 0.03), and high pre ECMO lactate level (OR: 1.24; p = 0.001) were associated with increased mortality. Sepsis did not predict mortality (OR: 1.83; p = 0.21). CONCLUSIONS Sepsis is a dreaded complication in patients with postcardiotomy cardiogenic shock, especially ECMO-associated sepsis. Preoperative risk factors could predict postoperative sepsis in ECMO patients.
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Affiliation(s)
- Tarek M Tantway
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Intensive Care Department, Cairo University, Cairo, Egypt
| | - Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy Department, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Makhlouf Belghith
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Ahmed A Osman
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Intensive Care Department, Cairo University, Cairo, Egypt
| | | | | | - Youssef A Elshoura
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Anesthesia and Critical Care Department, Tanta University, Tanta, Egypt
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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21
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Swedzky F, Barbagelata A, Perrone S, Kaplinsky E, Ducharme A. Emerging concepts in heart failure management and treatment: circulatory support with extracorporeal membrane oxygenation (ECMO). Drugs Context 2023; 12:dic-2022-7-7. [PMID: 36660011 PMCID: PMC9828876 DOI: 10.7573/dic.2022-7-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/02/2022] [Indexed: 01/04/2023] Open
Abstract
Circulatory support with extracorporeal membrane oxygenation (ECMO) is being increasingly used in several critical situations but evidence of its impact on outcomes is inconsistent. Understanding of the specific indications and appropriate timing of implantation of this technology might lead to improved results. Indeed, the line between success and futility may be sometimes very thin when facing a patient in critical condition. New techniques with lighter, simpler and effective devices are being developed. Hence, ECMO has become an accessible technology that is being increasingly used outside of the operating room by heart failure specialists, critical care cardiologists and intensivists. Proper timing of utilization and choice of device may lead to better outcomes. We herein aim to improve this knowledge gap by conducting a literature review to provide simple information, evidence-based indications and a practical approach for cardiologists who may encounter acutely ill adult patients that may be ECMO candidates. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.
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Affiliation(s)
- Federico Swedzky
- University of Montreal, Montreal’s Heart Institute, Montreal, Quebec, Canada
| | - Alejandro Barbagelata
- Catholic University of Argentine, Buenos Aires, Argentina,Sanatorio Fleni, Buenos Aires, Argentina
| | - Sergio Perrone
- Catholic University of Argentine, Buenos Aires, Argentina,Duke University School of Medicine, Durham, NC, USA
| | - Edgardo Kaplinsky
- Cardiology Unit, Medicine Department, Hospital Municipal de Badalona, Badalona, Spain
| | - Anique Ducharme
- University of Montreal, Montreal’s Heart Institute, Montreal, Quebec, Canada
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22
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Hartwig M, van Berkel V, Bharat A, Cypel M, Date H, Erasmus M, Hoetzenecker K, Klepetko W, Kon Z, Kukreja J, Machuca T, McCurry K, Mercier O, Opitz I, Puri V, Van Raemdonck D. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation. J Thorac Cardiovasc Surg 2023; 165:301-326. [PMID: 36517135 DOI: 10.1016/j.jtcvs.2022.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation. METHODS The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement. RESULTS The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively. CONCLUSIONS Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
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Affiliation(s)
- Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | | | | | | | - Hiroshi Date
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michiel Erasmus
- University Academic Center Groningen, Groningen, The Netherlands
| | | | | | | | - Jasleen Kukreja
- University of California San Francisco, San Francisco, Calif
| | - Tiago Machuca
- University of Florida College of Medicine, Gainesville, Fla
| | | | - Olaf Mercier
- Université Paris-Saclay and Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Varun Puri
- Washington University School of Medicine, St Louis, Mo
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Rajsic S, Breitkopf R, Bukumiric Z, Treml B. ECMO Support in Refractory Cardiogenic Shock: Risk Factors for Mortality. J Clin Med 2022; 11:jcm11226821. [PMID: 36431298 PMCID: PMC9698852 DOI: 10.3390/jcm11226821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a specialized temporary support for patients with refractory cardiogenic shock. The true value of this potentially lifesaving modality is still a subject of debate. Therefore, we aimed to investigate the overall in-hospital mortality and identify potential risk factors for mortality. METHODS We retrospectively analyzed the data of 453 patients supported with va-ECMO over a period of 14 years who were admitted to intensive care units of a tertiary university center in Austria. RESULTS We observed in-hospital mortality of 40% for patients with refractory cardiogenic shock. Hemorrhage, ECMO initiation on weekends, higher SAPS III score, and sepsis were identified as significant risk factors for mortality. Hemorrhage was the most common adverse event (46%), with major bleeding events dominating in deceased patients. Thromboembolic events occurred in 25% of patients, followed by sepsis (18%). CONCLUSIONS Although the rates of complications are substantial, a well-selected proportion of patients with refractory cardiogenic shock can be rescued from probable death. The reported risk factors could be used to increase the awareness of clinicians towards the development of new therapeutic concepts that may reduce their incidence.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Rajsic S, Treml B, Jadzic D, Breitkopf R, Oberleitner C, Popovic Krneta M, Bukumiric Z. Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications. Ann Intensive Care 2022; 12:93. [PMID: 36195759 PMCID: PMC9532225 DOI: 10.1186/s13613-022-01067-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock. METHODS We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size. RESULTS Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality. CONCLUSIONS Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, Cagliari, Italy
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Christoph Oberleitner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | | | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000, Belgrade, Serbia.
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Mariani S, De Piero ME, Ravaux JM, Saelmans A, Kawczynski MJ, van Bussel BCT, Di Mauro M, Willers A, Swol J, Kowalewski M, Li T, Delnoij TSR, van der Horst ICC, Maessen J, Lorusso R. Temporary mechanical circulatory support for COVID-19 patients: A systematic review of literature. Artif Organs 2022; 46:1249-1267. [PMID: 35490367 PMCID: PMC9325561 DOI: 10.1111/aor.14261] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/10/2021] [Accepted: 04/06/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Myocardial damage occurs in up to 25% of coronavirus disease 2019 (COVID-19) cases. While veno-venous extracorporeal life support (V-V ECLS) is used as respiratory support, mechanical circulatory support (MCS) may be required for severe cardiac dysfunction. This systematic review summarizes the available literature regarding MCS use rates, disease drivers for MCS initiation, and MCS outcomes in COVID-19 patients. METHODS PubMed/EMBASE were searched until October 14, 2021. Articles including adults receiving ECLS for COVID-19 were included. The primary outcome was the rate of MCS use. Secondary outcomes included mortality at follow-up, ECLS conversion rate, intubation-to-cannulation time, time on ECLS, cardiac diseases, use of inotropes, and vasopressors. RESULTS Twenty-eight observational studies (comprising both ECLS-only populations and ECLS patients as part of larger populations) included 4218 COVID-19 patients (females: 28.8%; median age: 54.3 years, 95%CI: 50.7-57.8) of whom 2774 (65.8%) required ECLS with the majority (92.7%) on V-V ECLS, 4.7% on veno-arterial ECLS and/or Impella, and 2.6% on other ECLS. Acute heart failure, cardiogenic shock, and cardiac arrest were reported in 7.8%, 9.7%, and 6.6% of patients, respectively. Vasopressors were used in 37.2%. Overall, 3.1% of patients required an ECLS change from V-V ECLS to MCS for heart failure, myocarditis, or myocardial infarction. The median ECLS duration was 15.9 days (95%CI: 13.9-16.3), with an overall survival of 54.6% and 28.1% in V-V ECLS and MCS patients. One study reported 61.1% survival with oxy-right ventricular assist device. CONCLUSION MCS use for cardiocirculatory compromise has been reported in 7.3% of COVID-19 patients requiring ECLS, which is a lower percentage compared to the incidence of any severe cardiocirculatory complication. Based on the poor survival rates, further investigations are warranted to establish the most appropriated indications and timing for MCS in COVID-19.
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Affiliation(s)
- Silvia Mariani
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Maria Elena De Piero
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Justine M. Ravaux
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Alexander Saelmans
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Michal J. Kawczynski
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care MedicineMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Care And Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands
| | - Michele Di Mauro
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Anne Willers
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Justyna Swol
- Department of Pneumology, Allergology and Sleep MedicineParacelsus Medical UniversityNurembergGermany
| | - Mariusz Kowalewski
- Clinical Department of Cardiac SurgeryCentral Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical EducationWarsawPoland
| | - Tong Li
- Department of Cardiothoracic, Transplantation and Vascular SurgeryHannover Medical SchoolHannoverGermany
| | - Thijs S. R. Delnoij
- Department of Intensive Care MedicineMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Department of Cardiology, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Iwan C. C. van der Horst
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Jos Maessen
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Roberto Lorusso
- Cardio‐Thoracic Surgery Department, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
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Martins Costa A, Halfwerk F, Wiegmann B, Neidlin M, Arens J. Trends, Advantages and Disadvantages in Combined Extracorporeal Lung and Kidney Support From a Technical Point of View. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:909990. [PMID: 35800469 PMCID: PMC9255675 DOI: 10.3389/fmedt.2022.909990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides pulmonary and/or cardiac support for critically ill patients. Due to their diseases, they are at high risk of developing acute kidney injury. In that case, continuous renal replacement therapy (CRRT) is applied to provide renal support and fluid management. The ECMO and CRRT circuits can be combined by an integrated or parallel approach. So far, all methods used for combined extracorporeal lung and kidney support present serious drawbacks. This includes not only high risks of circuit related complications such as bleeding, thrombus formation, and hemolysis, but also increase in technical workload and health care costs. In this sense, the development of a novel optimized artificial lung device with integrated renal support could offer important treatment benefits. Therefore, we conducted a review to provide technical background on existing techniques for extracorporeal lung and kidney support and give insight on important aspects to be addressed in the development of this novel highly integrated artificial lung device.
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Affiliation(s)
- Ana Martins Costa
- Engineering Organ Support Technologies Group, Department of Biomechanical Engineering, University of Twente, Enschede, Netherlands
- *Correspondence: Ana Martins Costa
| | - Frank Halfwerk
- Engineering Organ Support Technologies Group, Department of Biomechanical Engineering, University of Twente, Enschede, Netherlands
- Department of Cardiothoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - Bettina Wiegmann
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development, Hannover Medical School, Hanover, Germany
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
- German Center for Lung Research, BREATH, Hannover Medical School, Hanover, Germany
| | - Michael Neidlin
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- Engineering Organ Support Technologies Group, Department of Biomechanical Engineering, University of Twente, Enschede, Netherlands
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Duplex Analysis of Cannulated Vessels in Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation. Medicina (B Aires) 2022; 58:medicina58050671. [PMID: 35630088 PMCID: PMC9143327 DOI: 10.3390/medicina58050671] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/03/2022] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background and objectives: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) cannulas have major repercussions on vascular hemodynamics that can potentially lead to limb ischemia. Duplex ultrasound enables the non-invasive analysis of vascular hemodynamics. This study aims to describe the duplex parameters of the femoral vessels during V-A ECMO support, investigate differences between cannulated and non-cannulated vessels, and analyze the variations in the case of limb ischemia and intra-aortic balloon pumps (IABPs). Methods: Nineteen adults (≥18 years), supported with femoro-femoral V-A ECMO, underwent a duplex analysis of the superficial femoral arteries (SFAs) and veins (FVs). Measured parameters included flow velocities, waveforms, and vessel diameters. Results: 89% of patients had a distal perfusion cannula during duplex analysis and 21% of patients developed limb ischemia. The mean peak systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) of the SFAs on the cannulated side were, respectively, 42.4 and 21.4 cm/s. The SFAs on the non-cannulated side showed a mean PSV and EDV of 87.4 and 19.6 cm/s. All SFAs on the cannulated side had monophasic waveforms, whereas 63% of the SFAs on the non-cannulated side had a multiphasic waveform. Continuous/decreased waveforms were seen in 79% of the FVs on the cannulated side and 61% of the waveforms of the contralateral veins were respirophasic. The mean diameter of the FVs on the cannulated side, in patients who developed limb ischemia, was larger compared to the FVs on the non-cannulated side with a ratio of 1.41 ± 0.12. The group without limb ischemia had a smaller ratio of 1.03 ± 0.25. Conclusions: Femoral cannulas influence flow velocities in the cannulated vessels during V-A ECMO and major waveforms alternations can be seen in all SFAs on the cannulated side and most FVs on the cannulated side. Our data suggest possible venous stasis in the FV on the cannulated side, especially in patients suffering from limb ischemia.
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Dalia AA, Convissar D, Crowley J, Raz Y, Funamoto M, Wiener-Kronish J, Shelton K. The Role of Extracorporeal Membrane Oxygenation in COVID-19. J Cardiothorac Vasc Anesth 2022; 36:3668-3675. [PMID: 35659829 PMCID: PMC9087154 DOI: 10.1053/j.jvca.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/11/2022]
Abstract
An extracorporeal membrane oxygenation (ECMO) program is an important component in the management of patients with COVID-19, but it is imperative to implement a system that is well-supported by the institution and staffed with well-trained clinicians to both optimize patient outcomes and to keep providers safe. There are many unknowns related to COVID-19, and one of the most challenging aspects for clinicians is the lack of predictive knowledge as to why some patients fail medical therapy and require advanced support such as ECMO. These factors can create challenges during a time of resource scarcity and interruptions in the supply chain. In the current environment, in which resources are limited and an ongoing pandemic, healthcare practitioners need to focus on evidence-based best practice for supportive care of patients with COVID-19 in refractory respiratory or cardiac failure. with As experience is gained, a greater understanding will develop in this cohort of patients regarding need and timing of ECMO. As this pandemic continues, it will be important to compile and analyze multicentered data pertaining to patient-specific outcomes to help guide clinicians caring for patients with COVID-19 undergoing ECMO support. In this paper, the authors demonstrate the strategies utilized by a major quaternary care center in the utilization and management of ECMO for patients with COVID-19.
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ECMO Predictors of Mortality: A 10-Year Referral Centre Experience. J Clin Med 2022; 11:jcm11051224. [PMID: 35268314 PMCID: PMC8911127 DOI: 10.3390/jcm11051224] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Extracorporeal membrane oxygenation (ECMO) is a specialised life support modality for patients with refractory cardiac or respiratory failure. Multiple studies strived to evaluate the benefits of ECMO support, but its efficacy remains controversial with still inconsistent and sparse information. Methods: This retrospective analysis included patients with ECMO support, admitted between January 2010 and December 2019 at a tertiary university ECMO referral centre in Austria. The primary endpoint of the study was overall all-cause three-month mortality with risk factors and predictors of mortality. Secondary endpoints covered the analysis of demographic and clinical characteristics of patients needing ECMO, including incidence and type of adverse events during support. Results: In total, 358 patients fulfilled inclusion criteria and received ECMO support due to cardiogenic shock (258, 72%), respiratory failure (88, 25%) or hypothermia (12, 3%). In total, 41% (145) of patients died within the first three months, with the median time to death of 9 (1−87) days. The multivariate analysis identified hypothermia (HR 3.8, p < 0.001), the Simplified Acute Physiology Score III (HR 1.0, p < 0.001), ECMO initiation on weekends (HR 1.6, p = 0.016) and haemorrhage during ECMO support (HR 1.7, p = 0.001) as factors with higher risk for mortality. Finally, the most frequent adverse event was haemorrhage (160, 45%) followed by thrombosis. Conclusions: ECMO is an invasive advanced support system with a high risk of complications. Nevertheless, well-selected patients can be successfully rescued from life-threatening conditions by prolonging the therapeutic window to either solve the underlying problem or install a long-term assist device. Hypothermia, disease severity, initiation on weekends and haemorrhage during ECMO support increase the risk for mortality. In the case of decision making in a setting of limited (ICU) resources, the reported risk factors for mortality may be contemplable, especially when judging a possible ECMO support termination.
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Kukielski C, Jarrett Davis C, Saberi A, Chaudhary S. Veno-arteriovenous (V-AV) ECMO configuration: A single-center experience. J Card Surg 2022; 37:1254-1261. [PMID: 35191079 DOI: 10.1111/jocs.16348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/14/2021] [Accepted: 01/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND With increasing extracorporeal membrane oxygenation (ECMO) utilization over the last decade, clinicians have developed "hybrid" configurations to meet complex perfusion requirements. In the setting of differential hypoxemia, a veno-arteriovenous (V-AV) configuration provides oxygenated cardiac preload and hemodynamic support to satisfy physiologic demands. We aim to further characterize the patient population, indications, and outcomes associated with this hybrid configuration. METHODS We retrospectively reviewed all adult patients placed on V-AV ECMO at our institution from June 2016 to December 2019. Through a review of the electronic medical records, data describing demographic features, comorbidities, and ECMO-specific information were analyzed systematically. RESULTS 14 patients were placed on V-AV ECMO during the study period. Our cohort was 79% male with a median age of 54 and BMI of 30.3. These patients had a median SOFA-0 score of 15 and SAVE score of -12. Patients were treated with ECMO support for a median of 144.1 (IQR 98.5 - 183.1) hours, consisting of 0.2 (IQR 0 - 17.7) hours of VA and 92.4 (IQR 53.7 - 115.1) hours of V-AV followed by 67.4 (IQR 20.3 - 96.6) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%). CONCLUSION ECMO patients with recovering left ventricular function and persistent gas exchange abnormalities are at risk for developing differential hypoxemia. We describe an approach to utilizing V-AV configuration when the likelihood of differential hypoxemia is extremely high, with a survival rate that compares favorably to Extracorporeal Life Support Organization statistics and published case series.
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Affiliation(s)
- Casey Kukielski
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - C Jarrett Davis
- Department of Anesthesiology, Emory University Hospital, Atlanta, Georgia, USA
| | - Asif Saberi
- Division of Critical Care Medicine, Wellstar Kennestone Hospital, Marietta, Georgia, USA
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Tukacs M, Singh D, Halliday CA. ECMO During a Pandemic: A COVID-19 Quality Improvement Process. AACN Adv Crit Care 2021; 32:247-263. [PMID: 34490452 DOI: 10.4037/aacnacc2021446] [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: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation is a modified form of cardiopulmonary bypass and a complex adult critical care therapy. No evidence appears to exist on sustaining relevant quality nursing standards during a pandemic. The aim for this quality improvement process was to address nursing provision in real time related to extracorporeal membrane oxygenation in a pandemic, providing fundamentals for future readiness. The Ishikawa fishbone diagram and a Plan-Do-Study-Act cycle were methods used. Process changes included implementation of a communication algorithm, an alternative nursing care model, increased nursing staffing and leadership visibility, use of perfusion services for nursing task support, and minimized nursing documentation. Changes applied were successful. We recommend increasing nursing staffing volume and support resources, applying a communication algorithm, and minimizing documentation requirements. These strategies are generalizable to other clinical nursing areas in similar pandemics or disasters.
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Affiliation(s)
- Monika Tukacs
- Monika Tukacs is Nurse Clinician, Department of Nursing and Department of Cardiothoracic Intensive Care Unit, New York-Presbyterian/Columbia University Irving Medical Center, 177 Fort Washington Avenue, New York, NY 10032
| | - Darshani Singh
- Darshani Singh is Clinical Nurse Specialist, Department of Cardiac Service Line, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Catherine A Halliday
- Catherine A. Halliday is Director of Cardiac Services, Director Adult ECMO Services, Department of Nursing Administration, New York-Presbyterian/Columbia University Irving Medical Center; and Clinical Instructor, Columbia University School of Nursing, New York, New York
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Li C, Xie H, Li J, Qin B, Lu J, Zhang J, Lv L, Li B, Zhou C, Yin Y, Qiu H, Li Y, Liu X, Hou X. Dynamic and Hybrid Configurations for Extracorporeal Membrane Oxygenation: An Analysis of the Chinese Extracorporeal Life Support Registry. ASAIO J 2021; 68:547-552. [PMID: 34352813 DOI: 10.1097/mat.0000000000001535] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Dynamic or hybrid configurations for extracorporeal membrane oxygenation (ECMO) are needed when patient physiology or clinical conditions change. Dynamic configurations included configurations converting from veno-arterial (V-A) ECMO or veno-venous (V-V) ECMO to other forms. Hybrid configurations included venous-arteriovenous (V-AV) and venovenous-arterial (VV-A) ECMO. This study retrospectively analyzed a total of 3,814 ECMO cases (3,102 adult cases) reported to the Chinese Society of Extracorporeal Life Support from January 1, 2017 to December 31, 2019. Eight-three adult patients had dynamic or hybrid ECMO configurations, whose primary diagnoses included cardiogenic shock (33.7%), cardiac arrest (6.0%), acute respiratory failure (39.8%), septic shock (9.6%), multiple trauma (3.6%), pulmonary hypertension (3.6%), and others (3.6%). Configuration changes occurred in 37 patients with the initial configuration of VA (20 to VV, 13 to V-AV, and 4 to VV-A) and 27 with the initial configuration of VV (7 to VA, and 20 to V-AV). A total of 46 (55.4%) patients received hybrid configurations of V-AV and 10 (12.0%) received VV-A. Patients with the initial configuration of VV who converted to other configurations had higher in-hospital mortality (74.1%) than other initial configurations (VA 45.9%, V-AV 76.9%, VV-A 66.7%, P = 0.021). We concluded that dynamic or hybrid ECMO configurations were used in various underlying diseases, in which V-AV was most commonly used. Patients receiving VV ECMO for respiratory support initially, who then converted to other configurations for both respiratory and circulatory support, had significantly worst outcomes among the groups studied. The initial configuration should be selected carefully after thorough assessment of patient condition.
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Affiliation(s)
- Chenglong Li
- From the Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China Extracorporeal Support Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P.R. China Department of Critical Care Medicine, Henan Provincial People`s Hospital, Zhengzhou Henan, P.R. China Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, P.R. China Department of Emergency, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, P.R. China Department of Anesthesiology, Zhongshan City People's Hospital, Zhongshan, Guangdong, P.R. China Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, Jilin, P.R. China Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, P.R. China The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P.R. China
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Abstract
OBJECTIVES To describe the incidence and outcomes of radiologically confirmed acute CNS complications in extracorporeal membrane oxygenation patients at an Australian extracorporeal membrane oxygenation referral center and identify associated patient characteristics. DESIGN Retrospective cohort study. SETTING Single-center tertiary institution. PATIENTS Four-hundred twelve consecutive adult patients supported with extracorporeal membrane oxygenation from 2009 to 2017. RESULTS Fifty-five patients (13.3%) had a CNS complication confirmed by CT or MRI, including ischemic stroke (7.0%), intracerebral hemorrhage (3.4%), hypoxic ischemic encephalopathy (3.6%), and spinal cord injury (1.2%). CNS complication rates in the venoarterial, venovenous, and veno-pulmonary artery extracorporeal membrane oxygenation subgroups were 18.0%, 4.6%, and 13.6%, respectively. Neurologic complications were independently associated with the use of venoarterial extracorporeal membrane oxygenation (p = 0.002) and renal replacement therapy (p = 0.04). Sixty-five percent of patients with a neurologic complication died during their hospital admission compared with 32% of patients without this complication (p < 0.001). Venoarterial extracorporeal membrane oxygenation, renal replacement therapy, and days of extracorporeal membrane oxygenation support were also associated with hospital mortality and remained so after adjustment in a multivariable regression model (p = 0.01, p < 0.001, and p = 0.003, respectively). CONCLUSIONS CNS complications appear to occur more frequently in patients requiring circulatory as opposed to respiratory support on extracorporeal membrane oxygenation and are independently associated with mortality. It remains unclear if these complications are causative of a poor outcome or a marker of severity of the underlying condition. Further research is required to better elucidate modifiable or preventable aspects through better patient selection and change in ongoing care.
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Welker C, Huang J, Ramakrishna H. Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support. J Cardiothorac Vasc Anesth 2021; 36:2207-2219. [PMID: 34332842 DOI: 10.1053/j.jvca.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.
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Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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De Lazzari B, Iacovoni A, Mottaghy K, Capoccia M, Badagliacca R, Vizza CD, De Lazzari C. ECMO Assistance during Mechanical Ventilation: Effects Induced on Energetic and Haemodynamic Variables. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 202:106003. [PMID: 33618144 PMCID: PMC9754723 DOI: 10.1016/j.cmpb.2021.106003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/10/2021] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVE Simulation in cardiovascular medicine may help clinicians understand the important events occurring during mechanical ventilation and circulatory support. During the COVID-19 pandemic, a significant number of patients have required hospital admission to tertiary referral centres for concomitant mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Nevertheless, the management of ventilated patients on circulatory support can be quite challenging. Therefore, we sought to review the management of these patients based on the analysis of haemodynamic and energetic parameters using numerical simulations generated by a software package named CARDIOSIM©. METHODS New modules of the systemic circulation and ECMO were implemented in CARDIOSIM© platform. This is a modular software simulator of the cardiovascular system used in research, clinical and e-learning environment. The new structure of the developed modules is based on the concept of lumped (0-D) numerical modelling. Different ECMO configurations have been connected to the cardiovascular network to reproduce Veno-Arterial (VA) and Veno-Venous (VV) ECMO assistance. The advantages and limitations of different ECMO cannulation strategies have been considered. We have used literature data to validate the effects of a combined ventilation and ECMO support strategy. RESULTS The results have shown that our simulations reproduced the typical effects induced during mechanical ventilation and ECMO assistance. We focused our attention on ECMO with triple cannulation such as Veno-Ventricular-Arterial (VV-A) and Veno-Atrial-Arterial (VA-A) configurations to improve the hemodynamic and energetic conditions of a virtual patient. Simulations of VV-A and VA-A assistance with and without mechanical ventilation have generated specific effects on cardiac output, coupling of arterial and ventricular elastance for both ventricles, mean pulmonary pressure, external work and pressure volume area. CONCLUSION The new modules of the systemic circulation and ECMO support allowed the study of the effects induced by concomitant mechanical ventilation and circulatory support. Based on our clinical experience during the COVID-19 pandemic, numerical simulations may help clinicians with data analysis and treatment optimisation of patients requiring both mechanical ventilation and circulatory support.
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Affiliation(s)
| | | | | | - Massimo Capoccia
- Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, UK; Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
| | - Roberto Badagliacca
- Department of Cardiovascular Respiratory Nephrologic and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Carmine Dario Vizza
- Department of Cardiovascular Respiratory Nephrologic and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Claudio De Lazzari
- National Research Council, Institute of Clinical Physiology (IFC-CNR), Rome, Italy; Teaching University Geomedi, Tbilisi, Georgia.
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Selewski DT, Wille KM. Continuous renal replacement therapy in patients treated with extracorporeal membrane oxygenation. Semin Dial 2021; 34:537-549. [PMID: 33765346 PMCID: PMC8250911 DOI: 10.1111/sdi.12965] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life‐saving therapy utilized for patients with severe life‐threatening cardiorespiratory failure. Patients treated with ECMO are among the most severely ill encountered in critical care and are at high‐risk of developing multiple organ dysfunction, including acute kidney injury (AKI) and fluid overload. Continuous renal replacement therapy (CRRT) is increasingly utilized inpatients on ECMO to manage AKI and treat fluid overload. The indications for renal replacement therapy for patients on ECMO are similar to those of other critically ill populations; however, there is wide practice variation in how renal supportive therapies are utilized during ECMO. For patients requiring both CRRT and ECMO, CRRT may be connected directly to the ECMO circuit, or CRRT and ECMO may be performed independently. This review will summarize current knowledge of the epidemiology of AKI, indications and timing of CRRT, delivery of CRRT, and the outcomes of patients requiring CRRT with ECMO.
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Affiliation(s)
- David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Keith M Wille
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Navas-Blanco JR, Lifgren SA, Dudaryk R, Scott J, Loebe M, Ghodsizad A. Parallel veno-venous and veno-arterial extracorporeal membrane circuits for coexisting refractory hypoxemia and cardiovascular failure: a case report. BMC Anesthesiol 2021; 21:77. [PMID: 33711919 PMCID: PMC7952814 DOI: 10.1186/s12871-021-01299-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background The complexity of extracorporeal membrane oxygenation (ECMO) techniques continues to evolve. Different cannulation methods and configurations have been proposed as a response to a challenging cardiovascular and pulmonary physiology of the patients. The use of parallel ECMO circuits represents a unique and novel approach for patients with refractory respiratory failure and cardiovascular collapse with very large body surface areas. Case presentation We present the case of a 25-year-old morbidly obese male patient admitted for severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, requiring institution of double cannulation for veno-venous ECMO. Since his hypoxemia persisted, likely due to insufficient flows given his large body surface area, an additional drainage venous cannula was implemented to provide higher flows, temporarily addressing his oxygenation status. Unfortunately, the patient developed concomitant cardiogenic shock refractory to inotropic support and extracorporeal fluid removal, further worsening his oxygenation status, thus the decision was to institute four-cannulation/parallel-circuits veno-venous and veno-arterial ECMO, successfully controlling both refractory hypoxemia and cardiogenic shock. Conclusions Our case illustrates a novel and complex approach for combined severe ARDS and cardiovascular collapse through the use of parallel veno-venous and veno-arterial ECMO circuits, and exemplifies the expansion of ECMO techniques and its life-saving capabilities when conservative approaches are futile.
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Affiliation(s)
- Jose R Navas-Blanco
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1800 NW 10 Avenue (M-820), Miami, FL, 33136, USA.
| | - Sofia A Lifgren
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1800 NW 10 Avenue (M-820), Miami, FL, 33136, USA
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1800 NW 10 Avenue (M-820), Miami, FL, 33136, USA
| | - Jeffrey Scott
- Department of Critical Care, Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Matthias Loebe
- Department of Surgery, University of Miami Hospital, Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
| | - Ali Ghodsizad
- Department of Surgery, University of Miami Hospital, Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA
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(Mamiko Naito) 内麻, (Kota Hoshino) 星耕, (Megumi Koie) 鯉め, (Hiroko Ohkura) 大裕, (Hiroki Hatomoto) 鳩広, (Shintaro Yamasaki) 山慎, (Hiroyasu Ishikura) 石宏. COVID–19呼吸不全に対して3本目のカニューレを用いたVV–V ECMO管理(Role of triple cannulation venovenous extracorporeal membrane oxygenation in patients with coronavirus disease). NIHON KYUKYU IGAKUKAI ZASSHI: JOURNAL OF JAPANESE ASSOCIATION FOR ACUTE MEDICINE 2021. [PMCID: PMC8250890 DOI: 10.1002/jja2.12575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 32–year–old man with dry cough was admitted to a hospital for suspected coronavirus disease–induced pneumonia. The SARS–CoV–2 PCR test showed positive results on day 3 after symptom onset. Mechanical ventilation and venovenous extracorporeal membrane oxygenation (VV ECMO) were initiated for respiratory function deterioration on day 8 after symptom onset. However, ECMO did not maintain adequate oxygenation, and ventilator settings did not allow lung rest. Therefore, secondary ECMO transport was performed, and the patient was transferred to our center via ECMOnet. The reduced oxygenation level was attributed to the use of a small drainage cannula with consequently reduced ECMO circulation. Replacement of the small drainage cannula was unsafe; therefore, an additional drainage cannula was inserted, and the ECMO configuration was switched to VV–V ECMO, which established sufficient ECMO circulation and improved his oxygenation levels, and ventilator settings were modified for lung rest. He was weaned off ECMO on day 14, and retransferred to the previous hospital on day 21 after symptom onset. Selection of a drainage cannula of optimal size is important in patients who receive VV ECMO support. Conversion of a VV ECMO to VV–V ECMO configuration is useful in cases of insufficient ECMO blood flow.
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Affiliation(s)
- 内藤 麻巳子 (Mamiko Naito)
- 福岡大学病院救命救急センター(Department of Emergency & Critical Care Medicine, Fukuoka University Hospital)
| | - 星野 耕大 (Kota Hoshino)
- 福岡大学病院救命救急センター(Department of Emergency & Critical Care Medicine, Fukuoka University Hospital)
| | - 鯉江 めぐみ (Megumi Koie)
- 福岡大学病院救命救急センター(Department of Emergency & Critical Care Medicine, Fukuoka University Hospital)
| | - 大藏 裕子 (Hiroko Ohkura)
- 福岡大学病院救命救急センター(Department of Emergency & Critical Care Medicine, Fukuoka University Hospital)
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Shah A, Dave S, Goerlich CE, Kaczorowski DJ. Hybrid and parallel extracorporeal membrane oxygenation circuits. JTCVS Tech 2021; 8:77-85. [PMID: 34401820 PMCID: PMC8350616 DOI: 10.1016/j.xjtc.2021.02.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 12/05/2022] Open
Affiliation(s)
- Aakash Shah
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Sagar Dave
- Program in Trauma, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Corbin E Goerlich
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
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Early Findings after Implementation of Veno-Arteriovenous ECMO: A Multicenter European Experience. MEMBRANES 2021; 11:membranes11020081. [PMID: 33499236 PMCID: PMC7912524 DOI: 10.3390/membranes11020081] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/16/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquartiles, IQRs: 31–59) years) were identified: 16 were initially supported with VA-ECMO and 16 with VV-ECMO. The median time to V-AV conversion was 2 (1–5) days. After V-AV implantation, heart rate and norepinephrine dose significantly decreased, while PaO2 and SaO2 significantly increased compared to baseline values. Lactate levels significantly decreased from 3.9 (2.3–7.1) to 2.8 (1.4–4.4) mmol/L (p = 0.048). A significant increase in the overall ECMO blood flow (from 4.5 (3.8–5.0) to 4.9 (4.3–5.9) L/min; p < 0.01) was observed, with 3.0 (2.5–3.2) L/min for the arterial and 2.8 (2.1–3.6) L/min for the venous return flows. Conclusions: In ECMO patients with differential hypoxia or persistently low cardiac output syndrome, V-AV conversion was associated with improvement in some hemodynamic and respiratory parameters. A significant increase in the overall ECMO blood flow was also observed, with similar flow distributed into the arterial and venous return cannulas.
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45
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Lo Coco V, Swol J, De Piero ME, Massimi G, Chiarini G, Broman LM, Lorusso R. Dynamic extracorporeal life support: A novel management modality in temporary cardio-circulatory assistance. Artif Organs 2020; 45:427-434. [PMID: 33190316 DOI: 10.1111/aor.13869] [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] [Received: 06/28/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 12/14/2022]
Abstract
Extracorporeal life support (ECLS) is a temporary mechanical assistance method employed in acute respiratory, cardiocirculatory, and cardio-respiratory failure, refractory to conventional treatments. Patient's hemodynamic, respiratory and metabolic condition, or situations related to ECLS support or performance, may change during ECLS treatment. Provision of an additional drainage or perfusion cannula, or even of an additional associated device, for example, transaortic suction device or intra-aortic balloon pump (IABP), may be required to improve the ECLS/patient interaction and effects. Besides such a modified ECLS mode, however, a potential asset is represented by the "dynamic ECLS," which is the change of the flow direction (drainage or perfusion) in the already implanted cannula during the ECLS run. This particular management may be achieved in venous femoral or jugular cannulation, but it finds an even more appealing potential with the pulmonary artery (PA) cannulation. The PA allows the institution of a multitasking ECLS circuit, ranging from enhanced left ventricle (LV) unloading (drainage from the PA) to a right ventricular support or "central" veno-venous ECLS (perfusing the PA), tailored according to the patient hemodynamic, gas exchange, metabolic state, underlying cardiac involvement, and ECLS performance. Dynamic ECLS may, therefore, represent an additional option in ECLS management, particularly including the PA cannulation. Based on this new dynamic management of ECLS mode, we propose the Extracorporeal Life Support Organization nomenclature update.
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Affiliation(s)
- Valeria Lo Coco
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands
| | - Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Maria Elena De Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands.,Department of Anesthesia/Intensive Care, San Giovanni, Turin, Italy
| | - Giulio Massimi
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands.,Department of Cardiac Surgery, Circolo Hospital, University of Insurbia, Varese, Italy
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands.,Division of Anesthesiology, Intensive Care and Emergency medicine, Spedali Civili University, Brescia, Italy
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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46
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Neyra JA, Yessayan L, Thompson Bastin ML, Wille KM, Tolwani AJ. How To Prescribe And Troubleshoot Continuous Renal Replacement Therapy: A Case-Based Review. KIDNEY360 2020; 2:371-384. [PMID: 35373031 PMCID: PMC8741005 DOI: 10.34067/kid.0004912020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
Continuous RRT (CRRT) is the preferred dialysis modality for solute management, acid-base stability, and volume control in patients who are critically ill with AKI in the intensive care unit (ICU). CRRT offers multiple advantages over conventional hemodialysis in the critically ill population, such as greater hemodynamic stability, better fluid management, greater solute control, lower bleeding risk, and a more continuous (physiologic) approach of kidney support. Despite its frequent use, several aspects of CRRT delivery are still not fully standardized, or do not have solid evidence-based foundations. In this study, we provide a case-based review and recommendations of common scenarios and interventions encountered during the provision of CRRT to patients who are critically ill. Specific focus is on initial prescription, CRRT dosing, and adjustments related to severe hyponatremia management, concomitant extracorporeal membrane oxygenation support, dialysis catheter placement, use of regional citrate anticoagulation, and antibiotic dosing. This case-driven simulation is made as the clinical status of the patient evolves, and is on the basis of step-wise decisions made during the care of this patient, according to the specific patient's needs and the logistics available at the corresponding institution.
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Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Keith M Wille
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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48
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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49
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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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50
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Lari A, Abdulshakoor A, Zogheib E, Assaf N, Mojallal A, Lari AR, Bauer C, Sinna R. How to Save a Life From Macroscopic Fat Embolism: A Narrative Review of Treatment Options. Aesthet Surg J 2020; 40:1098-1107. [PMID: 31606739 DOI: 10.1093/asj/sjz277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Macroscopic fat embolism (MAFE) has grabbed the attention of the plastic surgery community in recent years because of its high mortality rate. Many articles on preventing MAFE during gluteal fat grafting are available in the literature. However, total prevention is difficult: a number of factors, both technical and human, mean that MAFE remains a potential complication. This review was written with the main goal of providing a treatment plan. MAFE shares many similar pathophysiologic and hemodynamic features with massive thrombotic pulmonary embolism (PE), especially the associated cardiopulmonary decompensation. Lessons learned from PE management were used to devise a management algorithm for MAFE. The use of extracorporeal membrane oxygenation and its potential application as a main modality of treatment for MAFE was explored. The lack of evidence in the literature for the treatment of MAFE, and its high mortality, lent urgency to the need to write an article on the management aspect in the form of a narrative review, to ensure that every plastic surgeon practicing gluteal fat grafting is knowledgeable about the treatment aspect of this deadly complication.
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Affiliation(s)
- Aqeel Lari
- University Hospital of Amiens and University Hospital of Lyon, Lyon, France
- plastic and reconstructive surgeon in private practice in Hawally, Kuwait
| | - Abeer Abdulshakoor
- Department of Plastic, Reconstructive, and Aesthetic Surgery, University Hospital of Amiens, Amiens, France
| | | | - Nizar Assaf
- Department of Plastic, Reconstructive, and Aesthetic Surgery, University Hospital of Amiens, Amiens, France
| | | | - Abdul-Reda Lari
- plastic and reconstructive surgeon in private practice in Hawally, Kuwait
| | - Christian Bauer
- Croix Rousse Hospital, University Hospital of Lyon, Lyon, France
| | - Raphael Sinna
- Department of Plastic, Reconstructive, and Aesthetic Surgery, University Hospital of Amiens, Amiens, France
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