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Liu X, Li Y, Jia J, Wang H, Xi Y, Sun A, Wang L, Deng X, Chen Z, Fan Y. Analysis of non-physiological shear stress-induced red blood cell trauma across different clinical support conditions of the blood pump. Med Biol Eng Comput 2024; 62:3209-3223. [PMID: 38802609 DOI: 10.1007/s11517-024-03121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 05/04/2024] [Indexed: 05/29/2024]
Abstract
Systematic research into device-induced red blood cell (RBC) damage beyond hemolysis, including correlations between hemolysis and RBC-derived extracellular vesicles, remains limited. This study investigated non-physiological shear stress-induced RBC damage and changes in related biochemical indicators under two blood pump clinical support conditions. Pressure heads of 100 and 350 mmHg, numerical simulation methods, and two in vitro loops were utilized to analyze the shear stress and changes in RBC morphology, hemolysis, biochemistry, metabolism, and oxidative stress. The blood pump created higher shear stress in the 350-mmHg condition than in the 100-mmHg condition. With prolonged blood pump operation, plasma-free hemoglobin and cholesterol increased, whereas plasma glucose and nitric oxide decreased in both loops. Notably, plasma iron and triglyceride concentrations increased only in the 350-mmHg condition. The RBC count and morphology, plasma lactic dehydrogenase, and oxidative stress across loops did not differ significantly. Plasma extracellular vesicles, including RBC-derived microparticles, increased significantly at 600 min in both loops. Hemolysis correlated with plasma triglyceride, cholesterol, glucose, and nitric oxide levels. Shear stress, but not oxidative stress, was the main cause of RBC damage. Hemolysis alone inadequately reflects overall blood pump-induced RBC damage, suggesting the need for additional biomarkers for comprehensive assessments.
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Affiliation(s)
- Xinyu Liu
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Jinze Jia
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Hongyu Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Anqiang Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Lizhen Wang
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Xiaoyan Deng
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China.
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Room 223, Building 5, No.37 Xueyuan Road, Haidian District, Beijing, 100083, China.
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Pisano DV, Ortoleva JP, Wieruszewski PM. Short-Term Neurologic Complications in Patients Undergoing Extracorporeal Membrane Oxygenation Support: A Review on Pathophysiology, Incidence, Risk Factors, and Outcomes. Pulm Ther 2024; 10:267-278. [PMID: 38937418 PMCID: PMC11339018 DOI: 10.1007/s41030-024-00265-z] [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: 04/08/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024] Open
Abstract
Regardless of the type, extracorporeal membrane oxygenation (ECMO) requires the use of large intravascular cannulas and results in multiple abnormalities including non-physiologic blood flow, hemodynamic perturbation, rapid changes in blood oxygen and carbon dioxide levels, coagulation abnormalities, and a significant systemic inflammatory response. Among other sequelae, neurologic complications are an important source of mortality and long-term morbidity. The frequency of neurologic complications varies and is likely underreported due to the high mortality rate. Neurologic complications in patients supported by ECMO include ischemic and hemorrhagic stroke, hypoxic brain injury, intracranial hemorrhage, and brain death. In addition to the disease process that necessitates ECMO, cannulation strategies and physiologic disturbances influence neurologic outcomes in this high-risk population. For example, the overall documented rate of neurologic complications in the venovenous ECMO population is lower, but a higher rate of intracranial hemorrhage exists. Meanwhile, in the venoarterial ECMO population, ischemia and global hypoperfusion seem to compose a higher percentage of neurologic complications. In what follows, the literature is reviewed to discuss the pathophysiology, incidence, risk factors, and outcomes related to short-term neurologic complications in patients supported by ECMO.
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Affiliation(s)
- Dominic V Pisano
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Jamel P Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Patrick M Wieruszewski
- Department of Anesthesiology, Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, 55906, USA.
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Mendrala K, Czober T, Darocha T, Hudziak D, Podsiadło P, Kosiński S, Jagoda B, Gocoł R. Hemolysis during open heart surgery in patients with hereditary spherocytosis - systematic review of the literature and case study. Perioper Med (Lond) 2024; 13:54. [PMID: 38858770 PMCID: PMC11163860 DOI: 10.1186/s13741-024-00411-w] [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: 09/02/2023] [Accepted: 05/27/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Due to the distinctive nature of cardiac surgery, patients suffering from hereditary spherocytosis (HS) are potentially at a high risk of perioperative complications resulting from hemolysis. Despite being the most prevalent cause of hereditary chronic hemolysis, the standards of surgical management are based solely on expert opinion. OBJECTIVE We analyze the risk of hemolysis in HS patients after cardiac surgery based on a systematic review of the literature. We also describe a case of a patient with hereditary spherocytosis who underwent aortic valve repair. METHODS This systematic review was registered in the PROSPERO international prospective register of systematic reviews (CRD42023417666) and included records from Embase, MEDLINE, Web of Science, and Google Scholar databases. The case study investigates a 38-year-old patient who underwent surgery for an aortic valve defect in mid-2022. RESULTS Of the 787 search results, 21 studies describing 23 cases of HS undergoing cardiac surgery were included in the final analysis. Hemolysis was diagnosed in five patients (one coronary artery bypass graft surgery, two aortic valve bioprosthesis, one ventricular septal defect closure, and one mitral valve plasty). None of the patients died in the perioperative period. Also, no significant clinical hemolysis was observed in our patient during the perioperative period. CONCLUSIONS The literature data show that hemolysis is not common in patients with HS undergoing various cardiac surgery techniques. The typical management of a patient with mild/moderate HS does not appear to increase the risk of significant clinical hemolysis. Commonly accepted beliefs about factors inducing hemolysis during cardiac surgery may not be fully justified and require further investigation.
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Affiliation(s)
- Konrad Mendrala
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland.
| | - Tomasz Czober
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Damian Hudziak
- Department of Cardiac Surgery, Upper-Silesian Medical Centre, Medical University of Silesia, Katowice, Poland
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Sylweriusz Kosiński
- Department of Intensive Interdisciplinary Therapy, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Bogusz Jagoda
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Radosław Gocoł
- Department of Cardiac Surgery, Upper-Silesian Medical Centre, Medical University of Silesia, Katowice, Poland
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Strudthoff LJ, Hesselmann F, Clauser JC, Arens J. Refurbishment of Extracorporeal Life Support Oxygenators in the Context of In Vitro Testing. ASAIO J 2023; 69:924-931. [PMID: 37314830 DOI: 10.1097/mat.0000000000001999] [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: 06/15/2023] Open
Abstract
Refurbishing single use extracorporeal membrane oxygenation (ECMO) oxygenators for in vitro research applications is common. However, the refurbishment protocols that are established in respective laboratories have never been evaluated. In the present study, we aim at proving the relevance of a well-designed refurbishing protocol by quantifying the burden of repeatedly reused oxygenators. We used the same three oxygenators in 5 days of 6 hours whole blood experiments. During each experiment day, the performance of the oxygenators was measured through the evaluation of gas transfer. Between experiment days, each oxygenator was refurbished applying three alternative refurbishment protocols based on purified water, pepsin and citric acid, and hydrogen peroxide solutions, respectively. After the last experiment day, we disassembled the oxygenators for visual inspection of the fiber mats. The refurbishment protocol based on purified water showed strong degeneration with a 40-50 %-performance drop and clearly visible debris on the fiber mats. Hydrogen peroxide performed better; nevertheless, it suffered a 20% decrease in gas transfer as well as clearly visible debris. Pepsin/citric acid performed best in the field, but also suffered from 10% performance loss and very few, but visible debris. The study showed the relevance of a well-suited and well-designed refurbishment protocol. The distinct debris on the fiber mats also suggests that reusing oxygenators is ill-advised for many experiment series, especially regarding hemocompatibility and in vivo testing. Most of all, this study revealed the relevance of stating the status of test oxygenators and, if refurbished, comment on the implemented refurbishment protocol in detail.
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Affiliation(s)
- Lasse J Strudthoff
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Felix Hesselmann
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Enmodes GmbH, Aachen, Germany
| | - Johanna C Clauser
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- From the Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Meservey A, Krishnan G, Green CL, Morrison S, Rackley CR, Kraft BD. U-Shaped Association Between Carboxyhemoglobin and Mortality in Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation. Crit Care Explor 2023; 5:e0957. [PMID: 37614802 PMCID: PMC10443764 DOI: 10.1097/cce.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Background Carbon monoxide (CO) is an endogenous signaling molecule that activates cytoprotective programs implicated in the resolution of acute respiratory distress syndrome (ARDS) and survival of critical illness. Because CO levels can be measured in blood as carboxyhemoglobin, we hypothesized that carboxyhemoglobin percent (COHb%) may associate with mortality. OBJECTIVES To examine the relationship between COHb% and outcomes in patients with ARDS requiring venovenous extracorporeal membrane oxygenation (ECMO), a condition where elevated COHb% is commonly observed. DESIGN Retrospective cohort study. SETTING Academic medical center ICU. PATIENTS Patients were included that had ARDS on venovenous ECMO. MEASUREMENTS AND MAIN RESULTS We examined the association between COHb% and mortality using a Cox proportional hazards model. Secondary outcomes including ECMO duration, ventilator weaning, and hospital and ICU length of stay were examined using both subdistribution and causal-specific hazard models for competing risks. We identified 109 consecutive patients for analysis. Mortality significantly decreased per 1 U increase in COHb% below 3.25% (hazard ratio [HR], 0.35; 95% CI, 0.15-0.80; p = 0.013) and increased per 1 U increase above 3.25% (HR, 4.7; 95% CI, 1.5-14.7; p = 0.007) reflecting a nonlinear association (p = 0.006). Each unit increase in COHb% was associated with reduced likelihood of liberation from ECMO and mechanical ventilation, and increased time to hospital and ICU discharge (all p < 0.05). COHb% was significantly associated with hemolysis but not with initiation of hemodialysis or blood transfusions. CONCLUSIONS In patients with ARDS on venovenous ECMO, COHb% is a novel biomarker for mortality exhibiting a U-shaped pattern. Our findings suggest that too little CO (perhaps due to impaired host signaling) or excess CO (perhaps due to hemolysis) is associated with higher mortality. Patients with low COHb% may exhibit the most benefit from future therapies targeting anti-oxidant and anti-inflammatory pathways such as low-dose inhaled CO gas.
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Affiliation(s)
- Amber Meservey
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Govind Krishnan
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Samantha Morrison
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Craig R Rackley
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Bryan D Kraft
- Department of Medicine, Duke University School of Medicine, Durham, NC
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Costantini S, Belliato M, Ferrari F, Gazzaniga G, Ravasi M, Manera M, De Piero ME, Curcelli A, Cardinale A, Lorusso R. A retrospective analysis of the hemolysis occurrence during extracorporeal membrane oxygenation in a single center. Perfusion 2023; 38:609-621. [PMID: 35225087 DOI: 10.1177/02676591211073768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO)-associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients. METHODS This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time. RESULTS Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = -215.307, p = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL (p = 0.001). CONCLUSIONS Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit-connected CRRT, as an equally important key factor triggering hemolysis.
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Affiliation(s)
- Silvia Costantini
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Mirko Belliato
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Fiorenza Ferrari
- UOC Anestesia e Rianimazione I, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Gazzaniga
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Marta Ravasi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Miriam Manera
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Antonio Curcelli
- Cardiac Anesthesia and Intensive Care ICLAS Rapallo, 18591GVM Care & Res, Rapallo, Italy
| | - Alessandra Cardinale
- Department of Statistical Sciences, 9311Sapienza University of Rome, Rome, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,118066Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherland
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Zeibi Shirejini S, Carberry J, McQuilten ZK, Burrell AJC, Gregory SD, Hagemeyer CE. Current and future strategies to monitor and manage coagulation in ECMO patients. Thromb J 2023; 21:11. [PMID: 36703184 PMCID: PMC9878987 DOI: 10.1186/s12959-023-00452-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can provide life-saving support for critically ill patients suffering severe respiratory and/or cardiac failure. However, thrombosis and bleeding remain common and complex problems to manage. Key causes of thrombosis in ECMO patients include blood contact to pro-thrombotic and non-physiological surfaces, as well as high shearing forces in the pump and membrane oxygenator. On the other hand, adverse effects of anticoagulant, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis are all established as causes of bleeding. Finding safe and effective anticoagulants that balance thrombosis and bleeding risk remains challenging. This review highlights commonly used anticoagulants in ECMO, including their mechanism of action, monitoring methods, strengths and limitations. It further elaborates on existing anticoagulant monitoring strategies, indicating their target range, benefits and drawbacks. Finally, it introduces several highly novel approaches to real-time anticoagulation monitoring methods including sound, optical, fluorescent, and electrical measurement as well as their working principles and future directions for research.
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Affiliation(s)
- Saeedreza Zeibi Shirejini
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Josie Carberry
- grid.1002.30000 0004 1936 7857Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Zoe K. McQuilten
- grid.1002.30000 0004 1936 7857Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, and Department of Clinical Haematology, Monash Health, Melbourne, VIC Australia
| | - Aidan J. C. Burrell
- grid.1623.60000 0004 0432 511XSchool of Medicine, Nursing, and Health Sciences, Clayton and Intensive Care Unit, Monash University, Alfred Hospital, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, VIC Australia
| | - Shaun D. Gregory
- grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Christoph E. Hagemeyer
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia
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Hoeren F, Görmez Z, Richter M, Troidl K. Deetect: A Deep Learning-Based Image Analysis Tool for Quantification of Adherent Cell Populations on Oxygenator Membranes after Extracorporeal Membrane Oxygenation Therapy. Biomolecules 2022; 12:1810. [PMID: 36551238 PMCID: PMC9776364 DOI: 10.3390/biom12121810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/27/2022] [Accepted: 12/01/2022] [Indexed: 12/09/2022] Open
Abstract
The strong interaction of blood with the foreign surface of membrane oxygenators during ECMO therapy leads to adhesion of immune cells on the oxygenator membranes, which can be visualized in the form of image sequences using confocal laser scanning microscopy. The segmentation and quantification of these image sequences is a demanding task, but it is essential to understanding the significance of adhering cells during extracorporeal circulation. The aim of this work was to develop and test a deep learning-supported image processing tool (Deetect), suitable for the analysis of confocal image sequences of cell deposits on oxygenator membranes at certain predilection sites. Deetect was tested using confocal image sequences of stained (DAPI) blood cells that adhered to specific predilection sites (junctional warps and hollow fibers) of a phosphorylcholine-coated polymethylpentene membrane oxygenator after patient support (>24 h). Deetect comprises various functions to overcome difficulties that occur during quantification (segmentation, elimination of artifacts). To evaluate Deetects performance, images were counted and segmented manually as a reference and compared with the analysis by a traditional segmentation approach in Fiji and the newly developed tool. Deetect outperformed conventional segmentation in clustered areas. In sections where cell boundaries were difficult to distinguish visually, previously defined post-processing steps of Deetect were applied, resulting in a more objective approach for the resolution of these areas.
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Affiliation(s)
- Felix Hoeren
- Department of Pharmacology, Max Planck Institute for Heart and Lung Research, 61231 Bad Nauheim, Germany
- Campus Kerckhoff, Justus Liebig University Giessen, 61231 Bad Nauheim, Germany
| | - Zeliha Görmez
- Department of Life Sciences and Engineering, TH Bingen, University of Applied Sciences, 55411 Bingen am Rhein, Germany
| | - Manfred Richter
- Campus Kerckhoff, Justus Liebig University Giessen, 61231 Bad Nauheim, Germany
- Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Kerstin Troidl
- Department of Pharmacology, Max Planck Institute for Heart and Lung Research, 61231 Bad Nauheim, Germany
- Department of Life Sciences and Engineering, TH Bingen, University of Applied Sciences, 55411 Bingen am Rhein, Germany
- Department of Vascular and Endovascular Surgery, Cardiovascular Surgery Clinic, University Hospital Frankfurt and Wolfgang Goethe University Frankfurt, 60590 Frankfurt, Germany
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Hemocompatibility challenge of membrane oxygenator for artificial lung technology. Acta Biomater 2022; 152:19-46. [PMID: 36089235 DOI: 10.1016/j.actbio.2022.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022]
Abstract
The artificial lung (AL) technology is one of the membrane-based artificial organs that partly augments lung functions, i.e. blood oxygenation and CO2 removal. It is generally employed as an extracorporeal membrane oxygenation (ECMO) device to treat acute and chronic lung-failure patients, and the recent outbreak of the COVID-19 pandemic has re-emphasized the importance of this technology. The principal component in AL is the polymeric membrane oxygenator that facilitates the O2/CO2 exchange with the blood. Despite the considerable improvement in anti-thrombogenic biomaterials in other applications (e.g., stents), AL research has not advanced at the same rate. This is partly because AL research requires interdisciplinary knowledge in biomaterials and membrane technology. Some of the promising biomaterials with reasonable hemocompatibility - such as emerging fluoropolymers of extremely low surface energy - must first be fabricated into membranes to exhibit effective gas exchange performance. As AL membranes must also demonstrate high hemocompatibility in tandem, it is essential to test the membranes using in-vitro hemocompatibility experiments before in-vivo test. Hence, it is vital to have a reliable in-vitro experimental protocol that can be reasonably correlated with the in-vivo results. However, current in-vitro AL studies are unsystematic to allow a consistent comparison with in-vivo results. More specifically, current literature on AL biomaterial in-vitro hemocompatibility data are not quantitatively comparable due to the use of unstandardized and unreliable protocols. Such a wide gap has been the main bottleneck in the improvement of AL research, preventing promising biomaterials from reaching clinical trials. This review summarizes the current state-of-the-art and status of AL technology from membrane researcher perspectives. Particularly, most of the reported in-vitro experiments to assess AL membrane hemocompatibility are compiled and critically compared to suggest the most reliable method suitable for AL biomaterial research. Also, a brief review of current approaches to improve AL hemocompatibility is summarized. STATEMENT OF SIGNIFICANCE: The importance of Artificial Lung (AL) technology has been re-emphasized in the time of the COVID-19 pandemic. The utmost bottleneck in the current AL technology is the poor hemocompatibility of the polymer membrane used for O2/CO2 gas exchange, limiting its use in the long-term. Unfortunately, most of the in-vitro AL experiments are unsystematic, irreproducible, and unreliable. There are no standardized in-vitro hemocompatibility characterization protocols for quantitative comparison between AL biomaterials. In this review, we tackled this bottleneck by compiling the scattered in-vitro data and suggesting the most suitable experimental protocol to obtain reliable and comparable hemocompatibility results. To the best of our knowledge, this is the first review paper focusing on the hemocompatibility challenge of AL technology.
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Chan CHH, Simmonds MJ, Fraser KH, Igarashi K, Ki KK, Murashige T, Joseph MT, Fraser JF, Tansley GD, Watanabe N. Discrete responses of erythrocytes, platelets, and von Willebrand factor to shear. J Biomech 2021; 130:110898. [PMID: 34896790 DOI: 10.1016/j.jbiomech.2021.110898] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/18/2021] [Accepted: 12/01/2021] [Indexed: 01/14/2023]
Abstract
Despite decades of technological advancements in blood-contacting medical devices, complications related to shear flow-induced blood trauma are still frequently observed in clinic. Blood trauma includes haemolysis, platelet activation, and degradation of High Molecular Weight von Willebrand Factor (HMW vWF) multimers, all of which are dependent on the exposure time and magnitude of shear stress. Specifically, accumulating evidence supports that when blood is exposed to shear stresses above a certain threshold, blood trauma ensues; however, it remains unclear how various constituents of blood are affected by discrete shears experimentally. The aim of this study was to expose blood to discrete shear stresses and evaluate blood trauma indices that reflect red cell, platelet, and vWF structure. Citrated human whole blood (n = 6) was collected and its haematocrit was adjusted to 30 ± 2% by adding either phosphate buffered saline (PBS) or polyvinylpyrrolidone (PVP). Viscosity of whole blood was adjusted to 3.0, 12.5, 22.5 and 37.5 mPa·s to yield stresses of 3, 6, 9, 12, 50, 90 and 150 Pa in a custom-developed shearing system. Blood samples were exposed to shear for 0, 300, 600 and 900 s. Haemolysis was measured using spectrophotometry, platelet activation using flow cytometry, and HMW vWF multimer degradation was quantified with gel electrophoresis and immunoblotting. For tolerance to 300, 600 and 900 s of exposure time, the critical threshold of haemolysis was reached after blood was exposed to 90 Pa for 600 s (P < 0.05), platelet activation and HMW vWF multimer degradation were 50 Pa for 600 s and 12 Pa for 300 s respectively (P < 0.05). Our experimental results provide simultaneous comparison of blood trauma indices and thus also the relation between shear duration and magnitude required to induce damage to red cells, platelets, and vWF. Our results also demonstrate that near-physiological shear stress (<12 Pa) is needed in order to completely avoid any form of blood trauma. Therefore, there is an urgent need to design low shear-flow medical devices in order to avoid blood trauma in this blood-contacting medical device field.
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Affiliation(s)
- Chris H H Chan
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; Faculty of Medicine, University of Queensland, Queensland, Australia.
| | - Michael J Simmonds
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Katharine H Fraser
- Department of Mechanical Engineering, University of Bath, Bath, United Kingdom
| | - Kosuke Igarashi
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; Department of Life Sciences, Systems Engineering and Science, Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, Japan
| | - Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Tomotaka Murashige
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Mary T Joseph
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; Faculty of Medicine, University of Queensland, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
| | - Geoff D Tansley
- School of Engineering and Built Environment, Griffith University, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - Nobuo Watanabe
- Department of Life Sciences, Systems Engineering and Science, Graduate School of Engineering and Science, Shibaura Institute of Technology, Saitama, Japan
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11
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Challenges in the Extracorporeal Membrane Oxygenation Era. MEMBRANES 2021; 11:membranes11110829. [PMID: 34832058 PMCID: PMC8620737 DOI: 10.3390/membranes11110829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022]
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12
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Zhang M, Pauls JP, Bartnikowski N, Haymet AB, Chan CHH, Suen JY, Schneider B, Ki KK, Whittaker AK, Dargusch MS, Fraser JF. Anti-thrombogenic Surface Coatings for Extracorporeal Membrane Oxygenation: A Narrative Review. ACS Biomater Sci Eng 2021; 7:4402-4419. [PMID: 34436868 DOI: 10.1021/acsbiomaterials.1c00758] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in critical care to manage patients with severe respiratory and cardiac failure. ECMO brings blood from a critically ill patient into contact with a non-endothelialized circuit which can cause clotting and bleeding simultaneously in this population. Continuous systemic anticoagulation is needed during ECMO. The membrane oxygenator, which is a critical component of the extracorporeal circuit, is prone to significant thrombus formation due to its large surface area and areas of low, turbulent, and stagnant flow. Various surface coatings, including but not limited to heparin, albumin, poly(ethylene glycol), phosphorylcholine, and poly(2-methoxyethyl acrylate), have been developed to reduce thrombus formation during ECMO. The present work provides an up-to-date overview of anti-thrombogenic surface coatings for ECMO, including both commercial coatings and those under development. The focus is placed on the coatings being developed for oxygenators. Overall, zwitterionic polymer coatings, nitric oxide (NO)-releasing coatings, and lubricant-infused coatings have attracted more attention than other coatings and showed some improvement in in vitro and in vivo anti-thrombogenic effects. However, most studies lacked standard hemocompatibility assessment and comparison studies with current clinically used coatings, either heparin coatings or nonheparin coatings. Moreover, this review identifies that further investigation on the thrombo-resistance, stability and durability of coatings under rated flow conditions and the effects of coatings on the function of oxygenators (pressure drop and gas transfer) are needed. Therefore, extensive further development is required before these new coatings can be used in the clinic.
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Affiliation(s)
- Meili Zhang
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Mechanical and Mining Engineering, The University of Queensland, Brisbane, Queensland 4072,Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Engineering and Built Environment, Griffith University, Southport, Queensland 4222, Australia
| | - Nicole Bartnikowski
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Queensland 4000, Australia
| | - Andrew B Haymet
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Chris H H Chan
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Engineering and Built Environment, Griffith University, Southport, Queensland 4222, Australia
| | - Jacky Y Suen
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Bailey Schneider
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Katrina K Ki
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology and ARC Center of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Matthew S Dargusch
- School of Mechanical and Mining Engineering, The University of Queensland, Brisbane, Queensland 4072,Australia
| | - John F Fraser
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia.,School of Medicine, Griffith University, Southport, Queensland 4222, Australia
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