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Calzuola ST, Newman G, Feaugas T, Perrault CM, Blondé JB, Roy E, Porrini C, Stojanovic GM, Vidic J. Membrane-based microfluidic systems for medical and biological applications. LAB ON A CHIP 2024; 24:3579-3603. [PMID: 38954466 DOI: 10.1039/d4lc00251b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Microfluidic devices with integrated membranes that enable control of mass transport in constrained environments have shown considerable growth over the last decade. Membranes are a key component in several industrial processes such as chemical, pharmaceutical, biotechnological, food, and metallurgy separation processes as well as waste management applications, allowing for modular and compact systems. Moreover, the miniaturization of a process through microfluidic devices leads to process intensification together with reagents, waste and cost reduction, and energy and space savings. The combination of membrane technology and microfluidic devices allows therefore magnification of their respective advantages, providing more valuable solutions not only for industrial processes but also for reproducing biological processes. This review focuses on membrane-based microfluidic devices for biomedical science with an emphasis on microfluidic artificial organs and organs-on-chip. We provide the basic concepts of membrane technology and the laws governing mass transport. The role of the membrane in biomedical microfluidic devices, along with the required properties, available materials, and current challenges are summarized. We believe that the present review may be a starting point and a resource for researchers who aim to replicate a biological phenomenon on-chip by applying membrane technology, for moving forward the biomedical applications.
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Affiliation(s)
- Silvia Tea Calzuola
- UMR7646 Laboratoire d'hydrodynamique (LadHyX), Ecole Polytechnique, Palaiseau, France.
- Eden Tech, Paris, France
| | - Gwenyth Newman
- Eden Tech, Paris, France
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Thomas Feaugas
- Eden Tech, Paris, France
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milan, Italy
| | | | | | | | | | - Goran M Stojanovic
- Faculty of Technical Sciences, University of Novi Sad, T. D. Obradovića 6, 21000 Novi Sad, Serbia
| | - Jasmina Vidic
- Micalis Institute, INRAE, AgroParisTech, Université Paris-Saclay, Jouy-en-Josas, France
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Wong ZY, Azimi M, Khamooshi M, Wickramarachchi A, Burrell A, Gregory SD. The impact of small movements with dual lumen cannulae during venovenous extracorporeal membrane oxygenation: A computational fluid dynamics analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 250:108186. [PMID: 38692252 DOI: 10.1016/j.cmpb.2024.108186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND OBJECTIVES Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) provides respiratory support to patients with severe lung disease failing conventional medical therapy. An essential component of the ECMO circuit are the cannulas, which drain and return blood into the body. Despite being anchored to the patient to prevent accidental removal, minor cannula movements are common during ECMO. The clinical and haemodynamic consequences of these small movements are currently unclear. This study investigated the risk of thrombosis and recirculation caused by small movements of a dual lumen cannula (DLC) in an adult using computational fluid dynamics. METHODS The 3D model of an AVALON Elite DLC (27 Fr) and a patient-specific vena cava and right atrium were generated for an adult patient on ECMO. The baseline cannula position was generated where the return jet enters the tricuspid valve. Alternative cannula positions were obtained by shifting the cannula 5 and 15 mm towards inferior (IVC) and superior (SVC) vena cava, respectively. ECMO settings of 4 L/min blood flow and pulsatile flow at SVC and IVC were applied. Recirculation was defined as a scalar value indicating the infused oxygenated blood inside the drainage lumen, while thrombosis risk was evaluated by shear stress, stagnation volume, washout, and turbulent kinetic energy. RESULTS Recirculation for all models was less than 3.1 %. DLC movements between -5 to 15 mm increased shear stress and turbulence kinetic energy up to 24.7 % and 11.8 %, respectively, compared to the baseline cannula position leading to a higher predicted thrombosis risk. All models obtained a complete washout after nine seconds except for when the cannula migrated 15 mm into the SVC, indicating persisting stasis and circulating zones. CONCLUSION In conclusion, small DLC movements were not associated with an increased risk of recirculation. However, they may increase the risk of thrombosis due to increased shear rate, turbulence, and slower washout of blood. Developing effective cannula securement devices may reduce this risk.
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Affiliation(s)
- Zhun Yung Wong
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Marjan Azimi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia.
| | - Mehrdad Khamooshi
- School of Mechanical, Medical and Process Engineering and the Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, Australia
| | - Avishka Wickramarachchi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Aidan Burrell
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; ANZ Intensive Care Research Centre (ANZIC-RC), Dept. of Epidemiology and Preventive Medicine, Monash University, Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia; School of Mechanical, Medical and Process Engineering and the Centre for Biomedical Technologies, Queensland University of Technology, Brisbane, Australia
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Hong Y, Shin S, Nasim U, Roberts KG, Potchernikov AS, Liu KY, Dufendach KA, Skoog DJ, Bacchetta M, Cook KE. Hemocompatibility Evaluation of a Novel Ambulatory Pulmonary Assist System Using a Lightweight Axial-Flow Pump. ASAIO J 2024:00002480-990000000-00481. [PMID: 38728744 DOI: 10.1097/mat.0000000000002227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
The Pulmonary Assist System (PAS) is currently under development as a wearable respiratory assist system. In this study, the hemocompatibility of the PAS's axial-flow mechanical pump (AFP) was compared to other contemporary mechanical pumps in an acute ovine model. The PAS was attached to a normal sheep in a venovenous configuration using one of three pumps: 1) AFP, 2) ReliantHeart HeartAssist 5 (control), or 3) Abbott Pedimag (control) (n = 5 each). Each sheep was supported on the PAS for 12 hours with two L/minute of blood flow and four L/minute of sweep gas. Hemolysis, coagulation, inflammation, and platelet activation and loss were compared among the groups. In this study, the plasma-free hemoglobin (pfHb) was less than 10 mg/dl in all groups. The pfHb was significantly lower in the AFP group compared to other groups. There was no significant clot formation in the pumps and oxygenators in all groups. Furthermore, no significant differences in coagulation (oxygenator resistance, fibrinopeptide A), inflammation (white blood cell counts, IL-8), and platelet activation and loss (p-selectin, platelet counts) were observed among the groups (all, p > 0.05). This study demonstrates equivalent hemocompatibility of the PAS's AFP to other contemporary mechanical pumps with a reduced level of hemolysis on startup.
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Affiliation(s)
- Yeahwa Hong
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Surgery
| | - Suji Shin
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Umar Nasim
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Kalliope G Roberts
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Alexander S Potchernikov
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Kimberly Y Liu
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Keith A Dufendach
- Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David J Skoog
- Advanced Respiratory Technologies, Inc, Pittsburgh, Pennsylvania
| | - Matthew Bacchetta
- Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keith E Cook
- From the Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Whitlock K, Rzewnicki D, Krieger B, Miller C, Creel-Bulos C. "Beyond waking and walking. Intensive rehabilitation in patients requiring extended durations of advanced mechanical circulatory support: A case series". Perfusion 2024; 39:840-848. [PMID: 36847239 DOI: 10.1177/02676591231159570] [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: 03/01/2023]
Abstract
Physical therapy (PT) utilization in patients requiring mechanical circulatory support (MCS) and extracorporeal membrane oxygenation (ECMO) has been reported; however, little is known about intensive rehabilitation and associated outcomes in patients requiring extended complex MCS and/or ECMO support. Authors sought to explore safety, feasibility and outcomes associated with active rehabilitation in patients requiring prolonged advanced MCS/ECMO support. Single-center retrospective series evaluated functional, clinical, and longitudinal outcomes of sample of eight critically ill, adult (≥18 years of age) patients who underwent a intensive rehabilitation while receiving prolonged MCS/ECMO through advanced configurations including: venovenous (VV-ECMO), venoarterial (VA-ECMO), oxygenator with right ventricular assist device (Oxy-RVAD) and right ventricular assist device (RVAD). 406 sessions were conducted; 246 during provision of advanced MCS/ECMO support. Incidence of major adverse events-accidental decannulation, migration of cannulas, circuit failure, hemorrhage, major flow limitations, and major hemodynamic instability-was 1.2 events per 100 sessions. None of reported major adverse events impeded longitudinal ability to participate in PT. Increased time to PT initiation was associated with a statistically significant increase in intensive care unit (ICU) length-of-stay (β1 1.93, CI 0.55-3.30) and reduced ambulatory distance during last session on MCS/ECMO (β1 -47.64, CI - 93.93, -1.66). All patients survived to hospital discharge and 12 months from sentinel hospitalization. Amongst those patients discharged to an inpatient rehabilitation center (n = 4), all were discharged home within 3 months. Findings support the safety and feasibility of active rehabilitational PT in patients requiring extended durations of advanced MCS/ECMO support. Moreover, it highlights potentially associated benefits of this degree of intensive rehabilitation for these unique patients. Further investigation is needed to identify associations with longitudinal clinical outcomes, as well as predictors of success in this population.
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Affiliation(s)
- Katelyn Whitlock
- Department of Physical Therapy, Ivester College of Health Sciences, Brenau University, Gainesville, GA, USA
- Department of Rehabilitation Therapy, Emory University Hospital, Atlanta, GA, USA
| | | | - Briana Krieger
- Department of Rehabilitation Therapy, Emory University Hospital, Atlanta, GA, USA
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Casey Miller
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Christina Creel-Bulos
- Emory Critical Care Center, Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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van Galen DJM, Meinders Q, Halfwerk FR, Arens J. ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients. ASAIO J 2024; 70:377-386. [PMID: 38324706 PMCID: PMC11057491 DOI: 10.1097/mat.0000000000002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.
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Affiliation(s)
- Danny J. M. van Galen
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Quint Meinders
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
| | - Frank R. Halfwerk
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
- Department of Cardiothoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Jutta Arens
- From the Faculty of Engineering Technologies, Department of Biomechanical Engineering, Engineering Organ Support Technologies, University of Twente, Enschede, the Netherlands
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Cucchi M, Mariani S, Kawczynski MJ, Shkurka E, Ius F, Comentale G, Hoskote A, Lorusso R. Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy. Perfusion 2024:2676591241240377. [PMID: 38652693 DOI: 10.1177/02676591241240377] [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: 04/25/2024]
Abstract
OBJECTIVE Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. METHODS PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. RESULTS Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65). CONCLUSION Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.
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Affiliation(s)
- Marta Cucchi
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Pediatric Intensive Care Unit, Queensland Children Hospital, Brisbane, QLD, Australia
| | - Silvia Mariani
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michal J Kawczynski
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Emma Shkurka
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Giuseppe Comentale
- IRCCS Policlinico Universitario Sant'Orsola-Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Aparna Hoskote
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Harris CS, Lee HJ, Alderete IS, Halpern SE, Gordee A, Jamieson I, Scales C, Hartwig MG. The cost of lung transplantation in the United States: How high is too high? JTCVS OPEN 2024; 18:407-431. [PMID: 38690426 PMCID: PMC11056443 DOI: 10.1016/j.xjon.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/02/2023] [Accepted: 01/05/2024] [Indexed: 05/02/2024]
Abstract
Objectives To identify patient and process factors that contribute to the high cost of lung transplantation (LTx) in the perioperative period, which may allow transplant centers to evaluate situations in which transplantation is most cost-effective to inform judicious resource allocation, avoid futile care, and reduce costs. Methods The MarketScan Research databases were used to identify 582 privately insured patients undergoing single or bilateral LTx between 2013 and 2019. The patients were subdivided into groups by disease etiology using the United Network of Organ Sharing classification system. Multivariable generalized linear models using a gamma distribution with a log link were fit to examine the associations between the etiology of lung disease and costs during the index admission, 3 months before admission, and 3 months after discharge. Results Our results indicate that the index admission contributed the most to the total transplantation costs compared to the 3 months before admission and after discharge. The regression-adjusted mean index hospitalization cost was 35% higher for patients with pulmonary vascular disease compared to those with obstructive lung disease ($527,156 vs $389,055). The use of extracorporeal membrane oxygenation, mechanical ventilation, and surgical complications in the post-transplantation period were associated with higher costs during the index admission. Surprisingly, age ≥55 was associated with lower costs during the index admission. Conclusions This analysis identifies pivotal factors influencing the high cost of LTx, emphasizing the significant impact of the index admission, particularly for patients with pulmonary vascular disease. These insights offer transplant centers an opportunity to enhance cost-effectiveness through judicious resource allocation and service bundling, ultimately reducing overall transplantation costs.
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Affiliation(s)
- Chelsea S. Harris
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Hui-Jie Lee
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Isaac S. Alderete
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | | | - Alexander Gordee
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Ian Jamieson
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Charles Scales
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Hunt ML, Crespo MM, Richards TJ, Bermudez F, Courtwright A, Usman A, Spelde AE, Diamond J, Patel N, Cantu E, Christie J, Clausen E, Cevasco M, Ahya V, Bermudez CA. Lung transplant outcomes after acute respiratory distress syndrome requiring extracorporeal life support: Lessons from the COVID-19 pandemic. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00010-2. [PMID: 38199292 DOI: 10.1016/j.jtcvs.2023.12.028] [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: 05/06/2023] [Revised: 11/08/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Lung transplant for acute respiratory distress syndrome in patients supported with extracorporeal membrane oxygenation was rare before 2020, but was rapidly adopted to rescue patients with COVID-19 with lung failure. This study aims to compare the outcomes of patients who underwent lung transplant for COVID-associated acute respiratory distress syndrome and non-COVID acute respiratory distress syndrome, and to assess the impact of type and duration of extracorporeal membrane oxygenation support on survival. METHODS Using the United Network for Organ Sharing database, we identified 311 patients with acute respiratory distress syndrome who underwent lung transplant from 2007 to 2022 and performed a retrospective analysis of the patients who required extracorporeal membrane oxygenation preoperatively, stratified by COVID-associated acute respiratory distress syndrome and non-COVID acute respiratory distress syndrome listing diagnoses. The primary outcome was 1-year survival. Secondary outcomes included the effect of type and duration of extracorporeal membrane oxygenation on survival. RESULTS During the study period, 236 patients with acute respiratory distress syndrome and preoperative extracorporeal membrane oxygenation underwent lung transplant; 181 patients had a listing diagnosis of COVID-associated acute respiratory distress syndrome (77%), and 55 patients had a listing diagnosis of non-COVID acute respiratory distress syndrome (23%). Patients with COVID-associated acute respiratory distress syndrome were older, were more likely to be female, had higher body mass index, and spent longer on the waitlist (all P < .02) than patients with non-COVID acute respiratory distress syndrome. The 2 groups had similar 1-year survival (85.8% vs 81.1%, P = .2) with no differences in postoperative complications. Patients with COVID-associated acute respiratory distress syndrome required longer times on extracorporeal membrane oxygenation pretransplant (P = .02), but duration of extracorporeal membrane oxygenation support was not a predictor of 1-year survival (P = .2). CONCLUSIONS Despite prolonged periods of pretransplant extracorporeal membrane oxygenation support, selected patients with acute respiratory distress syndrome can undergo lung transplant safely with acceptable short-term outcomes. Appropriate selection criteria and long-term implications require further analysis.
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Affiliation(s)
- Mallory L Hunt
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas J Richards
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | | | - Andrew Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Asad Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pa
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pa
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Namrata Patel
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Edward Cantu
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Emily Clausen
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Vivek Ahya
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Christian A Bermudez
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
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Ehrsam JP, Meier Adamenko O, Pannu M, Markus Schöb O, Inci I. Lung transplantation in children. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S119-S133. [PMID: 38584780 PMCID: PMC10995684 DOI: 10.5606/tgkdc.dergisi.2024.25806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 04/09/2024]
Abstract
Lung transplantation is a well-established treatment for children facing advanced lung disease and pulmonary vascular disorders. However, organ shortage remains highest in children. For fitting the small chest of children, transplantation of downsized adult lungs, lobes, or even segments were successfully established. The worldwide median survival after pediatric lung transplantation is currently 5.7 years, while under consideration of age, underlying disease, and peri- and posttransplant center experience, median survival of more than 10 years is reported. Timing of referral for transplantation, ischemia-reperfusion injury, primary graft dysfunction, and acute and chronic rejection after transplantation remain the main challenges.
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Affiliation(s)
- Jonas Peter Ehrsam
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | | | | | - Othmar Markus Schöb
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | - Ilhan Inci
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
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Polastri M, Eden A, Loforte A, Dell'Amore A, Antonini MV, Riera J, Barrett NA, Swol J. Physiotherapy for patients on extracorporeal membrane oxygenation support: How, When, and Who. An international EuroELSO survey. Perfusion 2024; 39:162-173. [PMID: 36239077 DOI: 10.1177/02676591221133657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Extracorporeal membrane oxygenation (ECMO) continues to play an essential role in organ support in cardiogenic shock or acute respiratory distress syndrome and bridging to transplantation. The main purpose of the present survey was to define which clinical and organizational practices are adopted for the administration of physiotherapy in adult patients undergoing ECMO support worldwide. METHODS This international survey was conceived in November 2021. The survey launch was announced at the 10th EuroELSO (European ELSO chapter) Congress, London, May 2022. RESULTS The survey returned 32 questionnaires from 29 centers across 14 countries. 17 centers (53.1%) had more than 30 intensive care unit beds available and most (46.8%) were able to care for five to 10 patients on extracorporeal life support simultaneously. The predominant physiotherapist-to-patient ratio was 1:>5 (37.5%); physiotherapy was available 5/7 days and 7/7 days by 31.2% and 25% respectively. Respiratory physiotherapy was not defined by a specific protocol in most centers (46.8%) while 31.2% declared that the treatment commences less than 12 h after sedation is stopped/reduced. Mostly, early physiotherapy in non-cooperative ventilated patients was provided within the first 48 h (68.6%) and consisted of as passive range of motion, in-bed positioning, and splinting. Postural passages and sitting were provided to patients and walking was included in those advanced motor activities which are part of the treatment. CONCLUSION Physiotherapy in patients on ECLS is feasible, however substantial variability exists between centers with a trend of delivering not protocolized and understaffed rehabilitation practices.
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Affiliation(s)
- Massimiliano Polastri
- Department of Continuity of Care and Disability, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Allaina Eden
- Department of Rehabilitation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Antonio Loforte
- Department of Cardiac-Thoracic-Vascular Diseases, Cardiac Surgery and Transplantation, IRCCS Azienda, Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Dell'Amore
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, Division of Thoracic Surgery, University of Padua, Padua, Italy
| | - Marta Velia Antonini
- Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Jordi Riera
- Critical Care Department, Vall D´Hebron Research Institute, Barcelona, Spain
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University, Nuremberg, Germany
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11
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Bhatt HV, Fritz AV, Feinman JW, Subramani S, Malhotra AK, Townsley MM, Weiner MM, Sharma A, Teixeira MT, Lee J, Linganna RE, Waldron NH, Shapiro AB, Mckeon J, Hanada S, Ramakrishna H, Martin AK. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023. J Cardiothorac Vasc Anesth 2024; 38:16-28. [PMID: 38040533 DOI: 10.1053/j.jvca.2023.10.030] [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: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 12/03/2023]
Abstract
This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.
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Affiliation(s)
- Himani V Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita K Malhotra
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Miguel T Teixeira
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer Lee
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Regina E Linganna
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nathan H Waldron
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Anna Bovill Shapiro
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - John Mckeon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Satoshi Hanada
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL.
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Bermudez C, Bermudez F, Courtwright A, Richards T, Diamond J, Cevasco M, Blumberg E, Christie J, Usman A, Crespo MM. Lung transplantation for COVID-2019 respiratory failure in the United States: Outcomes 1-year posttransplant and the impact of preoperative extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg 2024; 167:384-395.e3. [PMID: 37087098 PMCID: PMC10121065 DOI: 10.1016/j.jtcvs.2023.04.016] [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: 12/21/2022] [Revised: 04/09/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Patients with end-stage respiratory failure after severe coronavirus disease 2019 (COVID-19) infection may benefit from lung transplant; however, data on transplant outcomes and the impact of prolonged circulatory support before transplant in these patients are limited. METHODS We assessed survival, postoperative complications, and the impact of pretransplant extracorporeal membrane oxygenation (ECMO) in patients undergoing lung transplant in the United States from August 2020 through March 2022 using records validated by United Network for Organ Sharing experts and extracted from the United Network for Organ Sharing database. RESULTS In 305 patients with COVID-19-related respiratory failure and validated data, survival for up to 1-year posttransplant did not differ between 188 patients with COVID-19-related acute respiratory distress syndrome and 117 patients with post-COVID-19 pulmonary fibrosis (P = .8). Pretransplant ECMO support (median 66 days) was required in 191 patients (63%), and venovenous ECMO was used in 91.2% of patients. One-, 6-, and 12-month survival was not significantly different between patients requiring ECMO and patients without ECMO (95.8% vs 99.1%, 93.1% vs 96.4%, 84.8% vs 90.9%, P = .2) In addition, 1-year survival was similar in recipients requiring ECMO for COVID-19 lung failure and recipients requiring ECMO for non-COVID-19 restrictive lung failure (84.8% vs 78.0%, P = .1). CONCLUSIONS These findings suggest that lung transplant in patients with COVID-19 respiratory failure yields acceptable 1-year outcomes. Despite an often more complex postoperative course, prolonged ECMO pretransplant in well-selected patients was associated with adequate clinical and functional status.
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Affiliation(s)
- Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | | | - Andrew Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas Richards
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Emily Blumberg
- Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
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Tomioka Y, Miyoshi K, Tanaka S, Sugimoto S, Kanai R, Nikai T, Toyooka S, Yamane M. Successful management of temporary veno-venous extracorporeal membrane oxygenation for a pediatric lung transplant recipient with bronchiolitis obliterans syndrome awaiting lung re-transplantation: a case report. Surg Case Rep 2023; 9:163. [PMID: 37713011 PMCID: PMC10504144 DOI: 10.1186/s40792-023-01742-4] [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: 07/17/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation is an uncommon strategy in Japan owing to the severe donor shortage and absence of urgent allocation policy. Moreover, the use of veno-venous (VV) ECMO for immunosuppressed patients is controversial; thus, applying ECMO to patients who await lung re-transplantation is challenging. CASE PRESENTATION A 16-year-old lung transplant recipient with grade 3 bronchiolitis obliterans syndrome was waitlisted for lung re-transplantation. Eleven months later, he fell into severe respiratory acidosis with hypercapnia, which were not resolved with mechanical ventilation. VV ECMO was introduced to minimize lung stress and strain. Tracheostomy was additionally performed on day 5 after the start of ECMO, and respiratory condition swiftly improved; hence, the weaning process from VV ECMO began on day 9. Rehabilitation became implementable, and bilateral re-lung transplantation was successfully performed 6 months after the ECMO treatment. No critical complication related to the precedent use of ECMO was noted. CONCLUSIONS VV ECMO can be a feasible treatment option even for lung transplant candidates awaiting re-transplantation for a prolonged period. Introduction of ECMO and tracheostomy in the early deterioration stage may be crucial to successful subsequent patient management.
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Affiliation(s)
- Yasuaki Tomioka
- Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-Cho, Izumo, Shimane 693-8501 Japan
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kentaroh Miyoshi
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shin Tanaka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of General Thoracic Surgery and Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of General Thoracic Surgery and Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Rie Kanai
- Department of Pediatrics, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Tetsuro Nikai
- Department of Anesthesiology, Faculty of Medicine, Shimane University, Izumo, Shimane Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaomi Yamane
- Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-Cho, Izumo, Shimane 693-8501 Japan
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Koh W, Zang H, Ollberding NJ, Ziady A, Hayes D. Extracorporeal membrane oxygenation bridge to pediatric lung transplantation: Modern era analysis. Pediatr Transplant 2023; 27:e14570. [PMID: 37424517 PMCID: PMC10530187 DOI: 10.1111/petr.14570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Survival outcomes of children on extracorporeal membrane oxygenation (ECMO) at time of lung transplant (LTx) remain unclear. METHODS Pediatric first-time LTx recipients transplanted between January 2000 and December 2020 were identified in the United Network for Organ Sharing Registry to compare post-transplant survival according to ECMO support at time of transplant. For a comprehensive analysis of the data, univariate analysis, multivariable Cox regression, and propensity score matching were performed. RESULTS During the study period, 954 children under 18 years of age underwent LTx with 40 patients on ECMO. We did not identify a post-LTx survival difference between patients receiving ECMO when compared to those that did not. A multivariable Cox regression model (Hazard ratio = 0.83; 95% confidence interval: 0.47, 1.45; p = .51) did not demonstrate an increased risk for death post-LTx. Lastly, a propensity score matching analysis, retaining 33 ECMO and 33 non-ECMO patients, further confirmed no post-LTx survival difference comparing ECMO to no ECMO cohorts (Hazard ratio = 0.98; 95% confidence interval: 0.48, 2.00; p = .96). CONCLUSIONS In this contemporary cohort of children, the use of ECMO at the time of LTx did not negatively impact post-transplant survival.
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Affiliation(s)
- Wonshill Koh
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Huaiyu Zang
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nicholas J. Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Assem Ziady
- Dvision of Bone Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Don Hayes
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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15
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Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S45-S60. [PMID: 36661435 DOI: 10.1097/pcc.0000000000003158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation). DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.
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Orozco-Hernandez E, DeLay TK, Gongora E, Bellot C, Rusanov V, Wille K, Tallaj J, Pamboukian S, Kaleekal T, Mcelwee S, Hoopes C. State of the art - Extracorporeal membrane oxygenation as a bridge to thoracic transplantation. Clin Transplant 2023; 37:e14875. [PMID: 36465026 DOI: 10.1111/ctr.14875] [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: 09/16/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has revolutionized the treatment of refractory cardiac and respiratory failure, and its use continues to increase, particularly in adults. However, ECMO-related morbidity and mortality remain high. MAIN TEXT In this review, we investigate and expand upon the current state of the art in thoracic transplant and extracorporeal life support (ELS). In particular, we examine recent increase in incidence of heart transplant in patients supported by ECMO; the potential changes in patient care and selection for transplant in the years prior to updated United Network for Organ Sharing (UNOS) organ allocation guidelines versus those in the years following, particularly where these guidelines pertain to ECMO; and the newly revived practice of heart-lung block transplants (HLT) and the prevalence and utility of ECMO support in patients listed for HLT. CONCLUSIONS Our findings highlight encouraging outcomes in patients bridged to transplant with ECMO, considerable changes in treatment surrounding the updated UNOS guidelines, and complex, diverse outcomes among different centers in their care for increasingly ill patients listed for thoracic transplant.
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Affiliation(s)
- Erik Orozco-Hernandez
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Kurt DeLay
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Enrique Gongora
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chris Bellot
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Victoria Rusanov
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keith Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Salpy Pamboukian
- Division of Cardiology, University of Washington, Birmingham, Alabama, USA
| | - Thomas Kaleekal
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sam Mcelwee
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Hoopes
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Johnson B, Dobkin SL, Josephson M. Extracorporeal membrane oxygenation as a bridge to transplant in neonates with fatal pulmonary conditions: A review. Paediatr Respir Rev 2022; 44:31-39. [PMID: 36464576 DOI: 10.1016/j.prrv.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022]
Abstract
Neonates with progressive respiratory failure should be referred early for subspecialty evaluation and lung transplantation consideration. ECMO should be considered for patients with severe cardiopulmonary dysfunction and a high likelihood of death while on maximal medical therapy, either in the setting of reversible medical conditions or while awaiting lung transplantation. While ECMO offers hope to neonates that experience clinical deterioration while awaiting transplant, the risks and benefits of this intervention should be considered on an individual basis. Owing to the small number of infant lung transplants performed yearly, large studies examining the outcomes of various bridging techniques in this age group do not exist. Multiple single-centre experiences of transplanted neonates have been described and currently serve as guidance for transplant teams. Future investigation of outcomes specific to neonatal transplant recipients bridged with advanced devices is needed.
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Affiliation(s)
- Brandy Johnson
- Division of Pediatric Pulmonary Medicine, UF Health Shands Children's Hospital, Gainesville, FL, USA; Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Shoshana Leftin Dobkin
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Maureen Josephson
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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18
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George TJ, Sheasby J, Taylor JE, Vaquera KA, Curry MW, Harness‐Brumley CL, Myers DP, Erwin GE, Lilly JC, Michael DiMaio J. Early mobilization in coronavirus-19 patients treated with extracorporeal membrane oxygenation. J Card Surg 2022; 37:4536-4542. [PMID: 36316816 PMCID: PMC9877644 DOI: 10.1111/jocs.17079] [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: 04/04/2022] [Revised: 08/14/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pneumonia can be associated with refractory respiratory failure requiring extracorporeal membrane oxygenation(ECMO). Although ECMO has helped many COVID patients, optimal management strategies for these patients remain unknown. METHODS We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. Six months into the pandemic, we changed our management strategy to focus on early mobilization. The early mobilization effort included tracheostomy within 48 h of cannulation, decreasing sedation, and an aggressive physical and occupational therapy program progressing toward early ambulation while on ECMO. The primary outcome measured was survival to discharge. The primary stratification was based on the mobilization strategy. RESULTS From 2020 to 2021, 47 COVID patients have been supported with ECMO at our institution. Five are still in the hospital on ECMO. 39 (83%) were supported with venovenous ECMO while 8 (17%) were supported with venoarterial or a right ventricular assist device type configuration. All 47 (100%) were cannulated at bedside with transesophageal echocardiographic guidance. The average age was 47 ± 9 years; 36(77%) were male; and 20 (43%) were Hispanic. The median duration of support was 22 (11-44) days. Excluding those who remain in the hospital and on support, overall survival to discharge was 24/42 (57%). When stratified by mobilization strategy, early tracheostomy and mobilization were associated with significantly improved survival (74% [17/23] vs. 37% [7/19], p = .02). There were no changes in patient acuity or duration of support throughout the study period. CONCLUSION In conclusion, early tracheostomy, decreased sedation, and aggressive mobilization of COVID-19 ECMO patients is associated with improved survival.
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Affiliation(s)
| | | | | | | | | | | | | | - Gary E. Erwin
- Baylor Scott and WhiteThe Heart HospitalPlanoTexasUSA
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Perez AA, Shah RJ. Critical Care of the Lung Transplant Patient. Clin Chest Med 2022; 43:457-470. [PMID: 36116814 DOI: 10.1016/j.ccm.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Lung transplantation is a therapeutic option for end-stage lung disease that improves survival and quality of life. Prelung transplant admission to the intensive care unit (ICU) for bridge to transplant with mechanical ventilation and extracorporeal membrane oxygenation (ECMO) is common. Primary graft dysfunction is an important immediate complication of lung transplantation with short- and long-term morbidity and mortality. Later transplant-related causes of respiratory failure necessitating ICU admission include acute cellular rejection, atypical infections, and chronic lung allograft dysfunction. Lung transplantation for COVID-19-related ARDS is increasingly common..
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Affiliation(s)
- Alyssa A Perez
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, 400 Parnassus Street, 5th Floor, San Francisco, CA 94143, USA.
| | - Rupal J Shah
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, 400 Parnassus Street, 5th Floor, San Francisco, CA 94143, USA
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Chiel LE, Winthrop ZA, Fynn-Thompson F, Midyat L. Extracorporeal membrane oxygenation and paracorporeal lung assist devices as a bridge to pediatric lung transplantation. Pediatr Transplant 2022; 26:e14289. [PMID: 35416395 DOI: 10.1111/petr.14289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND "Bridging" is a term used to describe the implementation of various treatment modalities to improve waitlist survival while a patient awaits lung transplantation. ECMO and PLAD are technologies used to bridge patients to lung transplantation. ECMO and PLAD are cardiopulmonary support systems that help move blood forward while using an artificial membrane to remove CO2 from and add O2 to the blood. Recent studies showed that these technologies are increasingly effective in bridging patients to lung transplantation, especially with optimizing patient selection, implementing physical rehabilitation and ambulation goals, standardization of management decisions, and increasing staff experience, among other considerations. We review these technologies, their roles as bridges to pediatric lung transplantation, as well as indications, contraindications, complications, and mortality rates. CONCLUSION Finally, we discuss the existing knowledge gaps and areas for future research to improve patient outcomes and understanding of lung assist devices.
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Affiliation(s)
- Laura E Chiel
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zachary A Winthrop
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Levent Midyat
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Early Mobilization for a Patient With a Right Ventricular Assist Device With an Oxygenator. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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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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Managing pulmonary arterial hypertension: how to select and facilitate successful transplantation. Curr Opin Organ Transplant 2022; 27:169-176. [PMID: 35649107 DOI: 10.1097/mot.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite improvements in available medical therapies, pulmonary arterial hypertension (PAH) remains a progressive, ultimately fatal disorder. Lung transplantation is a viable treatment option for PAH patients with advanced disease. RECENT FINDINGS Recent guidelines from the International Society of Heart and Lung Transplantation (ISHLT) have updated recommendations regarding time of referral and listing for lung transplantation in PAH. The new guidelines emphasize earlier referral for transplant evaluation to ensure adequate time for proper evaluation and listing. They also incorporate objective risk stratification criteria to assist in decision-making regarding timing of referral and listing. With regards to the transplant procedure, bilateral lung transplantation has largely supplanted heart-lung transplantation as the procedure of choice for transplantation for advanced PAH. Exceptions to this include patients with PAH because of congenital heart disease and those with concurrent LV dysfunction. Use of mechanical support via venoarterial ECMO initiated before transplantation and continued into the early postoperative period is emerging as a standard of care and may help to reduce early posttransplant mortality in this population. There has been increased recognition of the importance of WHO Group 3 pulmonary hypertension. Many of the lessons learned from PAH may be applied when transplanting patients with severe WHO Group 3 pulmonary hypertension. SUMMARY Patients with PAH present unique challenges with regards to transplantation that require a therapeutic approach distinct from other lung disorders. Lung transplantations for PAH are high-risk endeavors best performed at centers with expertise in management of both PAH and extracorporeal support.
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Patterson CM, Shah A, Rabin J, DiChiacchio L, Cypel M, Hoetzenecker K, Catarino P, Lau CL. EXTRACORPOREAL LIFE SUPPORT AS A BRIDGE TO LUNG TRANSPLANTATION: WHERE ARE WE NOW? J Heart Lung Transplant 2022; 41:1547-1555. [DOI: 10.1016/j.healun.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/21/2022] [Accepted: 06/05/2022] [Indexed: 11/16/2022] Open
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Soder SA, Fontena E, Salgado JC, Shahmohammadi A, Samano MN, Machuca TN. Inpatient Management of the Acutely Decompensating Lung Transplant Candidate. Thorac Surg Clin 2022; 32:121-134. [PMID: 35512931 DOI: 10.1016/j.thorsurg.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lung allocation in the US changed nearly 15 years ago from time accrued on the waiting list to disease severity and likelihood of posttransplant survival, represented by the lung allocation score (LAS). Notably, the risk of death within a year plays a stronger role on the score calculation than posttransplant survival. While this change was associated with the intended decrease in waitlist mortality (most recently reported at 14.6%), it was predictable that transplant teams would have to care for increasingly older and complex candidates and recipients. This urgency-based allocation also led centers to routinely consider transplanting patients with higher acuity, often hospitalized and, not infrequently, in the intensive care unit (ICU). According to the Scientific Registry for Transplant Recipients, from 2009 to 2019, the proportion of lung recipients hospitalized and those admitted to the ICU at the time of transplant increased from 18.9% to 26.8% and from 9.2% to 16.5%, respectively..
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Affiliation(s)
- Stephan A Soder
- Division of Thoracic Surgery and Lung Transplant Program, Irmandade da Santa Casa de Misericordia de Porto Alegre. 295, Professor Annes Dias Street. Hospital Dom Vicente Scherer, 6th Floor. Centro Histórico. Porto Alegre, Rio Grande do Sul 90020-090, Brazil
| | - Eduardo Fontena
- Lung Transplant Program, Hospital COPA D'Or, Rede D'Or Sao Luiz. 598, Figueiredo Magalhães Street. Room 39. Rio de Janeiro, Rio de Janeiro 22031-012, Brazil
| | - Juan C Salgado
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street. Gates Pavilion 9036. Philadelphia, PA 19104, USA
| | - Abbas Shahmohammadi
- Lung Transplant and ECMO Program, University of Florida Division of Pulmonary, Critical Care and Sleep Medicine 1600 SW Archer Road, Room M452 Gainesville, FL 32610-0225, USA
| | - Marcos N Samano
- Lung Transplant Program, Hospital Israelita Albert Einstein, Sao Paulo, Brazil. Av. Albert Eintein, 627, Bloco A1, sala 418 Sao Paulo, Sao Paulo 05652-900, Brazil; Division of Thoracic Surgery, University of Sao Paulo, Sao Paulo, Brazil. Av. Dr. Eneas Carvalho Aguiar, 44, Sao Paulo, São Paulo 05403-900, Brazil
| | - Tiago N Machuca
- Division of Thoracic Surgery, UF Lung Transplant Program, Adult ECMO, University of Florida, PO Box 100129, Gainesville, FL 32610-0129, USA.
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Driscoll J, Elkins J. Characteristics of Extracorporeal Membrane Oxygenation Education Vary in Entry-Level Doctor of Physical Therapy Programs. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kourek C, Nanas S, Kotanidou A, Raidou V, Dimopoulou M, Adamopoulos S, Karabinis A, Dimopoulos S. Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support. J Cardiovasc Dev Dis 2022; 9:jcdd9020034. [PMID: 35200688 PMCID: PMC8875180 DOI: 10.3390/jcdd9020034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.
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Affiliation(s)
- Christos Kourek
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Serafim Nanas
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Anastasia Kotanidou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Vasiliki Raidou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Maria Dimopoulou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
| | - Stamatis Adamopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Andreas Karabinis
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Stavros Dimopoulos
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 106 76 Athens, Greece; (C.K.); (S.N.); (A.K.); (V.R.); (M.D.)
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
- Correspondence: ; Tel.: +30-213-204-3389
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Rehabilitation of adult patients on extracorporeal membrane oxygenation: A scoping review. Aust Crit Care 2021; 35:575-582. [PMID: 34711492 DOI: 10.1016/j.aucc.2021.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The objective of this study was to conduct a scoping review to comprehensively map the breadth of literature related to the rehabilitation of adult patients whilst on extracorporeal membrane oxygenation (ECMO) and identify gaps and areas for future research. REVIEW METHOD USED This review was conducted using recommended frameworks for methods and reporting including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. DATE SOURCES We searched seven databases from inception to June 2021 and included all study designs and grey literature. REVIEW METHODS Eligibility screening was completed by two independent reviewers according to inclusion and exclusion criteria, with any disagreement resolved by consensus or with consultation with a third reviewer. Two independent reviewers extracted data related to intervention characteristics, patient outcomes, feasibility, safety, hospital outcomes, and mortality using a custom-designed piloted form. RESULTS Of 8507 records, 185 original studies met inclusion criteria, with the majority being small retrospective studies. Rehabilitation was more commonly reported in patients on veno-venous rather than veno-arterial ECMO. Ambulation was the most commonly reported intervention (51% of studies). Critical gaps were identified including incomplete reporting of the intervention along with heterogeneity in the type and timing of outcome measures. Less than 50% of patients met eligibility criteria to participate, but screening for eligibility was infrequently reported (9% of studies). Delivery of rehabilitation during ECMO may be facilitated by an expert multidisciplinary team, along with a strategy that targets low sedation levels and an upper body cannulation approach. CONCLUSIONS Rehabilitation during ECMO is an emerging area of research and mostly consisted of small retrospective single-centre studies. Future research requires more robust methodological designs that include comprehensive screening of potential candidates with reporting of eligibility, more detailed descriptions of the rehabilitation interventions, inclusion of a core outcome set with defined measurement instruments, and consistent timing of outcome measurement.
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Copeland H, Levine D, Morton J, Hayanga JA. Acute respiratory distress syndrome in the cardiothoracic patient: State of the art and use of veno-venous extracorporeal membrane oxygenation. ACTA ACUST UNITED AC 2021; 8:97-103. [PMID: 34723221 PMCID: PMC8541831 DOI: 10.1016/j.xjon.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 10/12/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Hannah Copeland
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
- Indiana University School of Medicine Fort Wayne, Fort Wayne, Ind
- Address for reprints: Hannah Copeland, MD, Indiana University–Fort Wayne School of Medicine, 7910 W Jefferson Blvd, Suite 102, Fort Wayne, IN 46804.
| | - Deborah Levine
- Division of Pulmonary Critical Care and Lung Transplantation, Department of Medicine, University of Texas San Antonio, San Antonio, Tex
| | - John Morton
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
| | - J.W. Awori Hayanga
- Department of Thoracic and Cardiovascular Surgery, West Virginia University, Morgantown, WVa
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Mortality after Lung Transplantation for Children Bridged with Extracorporeal Membrane Oxygenation. Ann Am Thorac Soc 2021; 19:415-423. [PMID: 34619069 DOI: 10.1513/annalsats.202103-250oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge waitlisted children failing conventional respiratory support to lung transplantation. OBJECTIVES To compare in-hospital mortality and a composite outcome of 1-year mortality or re-transplantation in children bridged with ECMO with those on mechanical ventilation (MV), and neither support. METHODS The United Network for Organ Sharing (UNOS) was used to analyze lung transplant recipients, aged ≤ 20 y, from January 2004 to August 2019. Recipients were categorized according to level of respiratory support at time of transplant, including ECMO, MV, or neither. Multivariable analysis was used to evaluate support type and in-hospital mortality. RESULTS Of 1,014 children undergoing lung transplant, 68 (6.7%) required ECMO as a bridge-to-transplant, 144 (14.2%) MV, and 802 (79.1%) neither. Primary diagnosis in the ECMO cohort included cystic fibrosis (43%), pneumonia/ARDS (10.3%), interstitial pulmonary fibrosis (7.4%) and pulmonary hypertension (5.9%). Number of patients bridged with ECMO increased throughout the study period from none in 2004 to 16.7% in 2018. Multivariable analysis showed bridging with both ECMO (aOR = 3.57; 95% CI: 1.42, 8.97) and MV (aOR = 2.67; 95% CI: 1.26, 5.57) increased in-hospital mortality after lung transplantation. However, there was no difference in composite outcome of mortality and re-transplantation at 1-year between the three groups. CONCLUSIONS ECMO to bridge children to lung transplantation has increased. Despite this, ECMO is a high-risk bridge strategy for children awaiting lung transplantation. Future research should target interventions that can be focused on improving survival in these patients.
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Hesselmann F, Arnemann D, Bongartz P, Wessling M, Cornelissen C, Schmitz-Rode T, Steinseifer U, Jansen SV, Arens J. Three-dimensional membranes for artificial lungs: Comparison of flow-induced hemolysis. Artif Organs 2021; 46:412-426. [PMID: 34606117 DOI: 10.1111/aor.14081] [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: 05/25/2021] [Revised: 08/11/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Membranes based on triply periodic minimal surfaces (TPMS) have proven a superior gas transfer compared to the contemporary hollow fiber membrane (HFM) design in artificial lungs. The improved oxygen transfer is attributed to disrupting the laminar boundary layer adjacent to the membrane surface known as main limiting factor to mass transport. However, it requires experimental proof that this improvement is not at the expense of greater damage to the blood. Hence, the aim of this work is a valid statement regarding the structure-dependent hemolytic behavior of TPMS structures compared to the current HFM design. METHODS Hemolysis tests were performed on structure samples of three different kind of TPMS-based designs (Schwarz-P, Schwarz-D and Schoen's Gyroid) in direct comparison to a hollow fiber structure as reference. RESULTS The results of this study suggest that the difference in hemolysis between TPMS membranes compared to HFMs is small although slightly increased for the TPMS membranes. There is no significant difference between the TPMS structures and the hollow fiber design. Nevertheless, the ratio between the achieved additional oxygen transfer and the additional hemolysis favors the TPMS-based membrane shapes. CONCLUSION TPMS-shaped membranes offer a safe way to improve gas transfer in artificial lungs.
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Affiliation(s)
- Felix Hesselmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Daniel Arnemann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Patrick Bongartz
- Chair of Chemical Process Engineering, RWTH Aachen University, Aachen, Germany
| | - Matthias Wessling
- Chair of Chemical Process Engineering, RWTH Aachen University, Aachen, Germany.,DWI-Leibniz Institute for Interactive Materials, RWTH Aachen University, Aachen, Germany
| | - Christian Cornelissen
- Department of Pneumology and Internal Intensive Care Medicine, Medical Clinic V, RWTH Aachen University Hospital, Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Sebastian Victor Jansen
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany.,Chair of Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering, Technology University of Twente, Twente, The Netherlands
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Morrow BM. Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach. Transl Pediatr 2021; 10:2845-2857. [PMID: 34765506 PMCID: PMC8578759 DOI: 10.21037/tp-20-324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/26/2021] [Indexed: 12/13/2022] Open
Abstract
The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.
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Affiliation(s)
- Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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Keshavamurthy S, Bazan V, Tribble TA, Baz MA, Zwischenberger JB. Ambulatory extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 37:366-379. [PMID: 34483506 PMCID: PMC8408364 DOI: 10.1007/s12055-021-01210-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 11/25/2022] Open
Abstract
Ambulatory extracorporeal membrane oxygenation (ECMO) has shown promise as a bridge to lung transplantation. The primary goal of ambulatory ECMO is to provide enough gas exchange to allow patients to participate in preoperative physical therapy. Various strategies of ambulatory ECMO are utilized depending upon patients’ need. A wide spectrum of ECMO configurations is available to tackle this situation. We discuss those configurations in this article.
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Affiliation(s)
- Suresh Keshavamurthy
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
| | - Vanessa Bazan
- University of Kentucky College of Medicine, William R. Willard Medical Education Building, MN 150, Lexington, KY 40536 USA
| | - Thomas Andrew Tribble
- Mechanical Circulatory Support Coordinator, MCS Department, Gill Heart & Vascular Institute, 1000 S. Limestone Pav A.08.273, Lexington, KY 40536 USA
| | - Maher Afif Baz
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
| | - Joseph Bertram Zwischenberger
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
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Patrick K, Adams A. Mobilization of Patients Receiving Extracorporeal Membrane Oxygenation Before Lung Transplant. Crit Care Nurse 2021; 41:39-45. [PMID: 34333616 DOI: 10.4037/ccn2021689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation is increasingly used to provide cardiopulmonary support to patients awaiting lung transplant. Although studies have shown that these patients benefit from early mobilization, the care team often has concerns about related complications, particularly for patients requiring femoral cannulation. OBJECTIVE To assess the safety of mobilizing patients receiving extracorporeal membrane oxygenation before lung transplant using a standardized mobility protocol. METHODS A retrospective review was performed of the electronic health records of patients receiving extracorporeal membrane oxygenation before or immediately after lung transplant who were mobilized according to a standardized protocol from April through October 2018. The setting was an 18-bed cardiothoracic intensive care unit in a Magnet-designated teaching hospital. Patients were helped to ambulate by an interdisciplinary team, with careful assessment for any related complications. RESULTS During the study period, 37 patients received extracorporeal membrane oxygenation, and 9 were mobilized. Two hundred forty-two therapy sessions were conducted involving 47 700 feet of ambulation. Patients experienced the following complications: chugging (1 patient), decrease in flow rate (2 patients), bleeding at the cannula site (2 patients), neck hyperextension (1 patient), fear/anxiety (1 patient), and shortness of breath (2 patients). Bleeding and neck hyperextension led to discontinuation of therapy until the problems were resolved. No changes were made to the protocol. CONCLUSIONS Patients receiving extracorporeal membrane oxygenation before lung transplant, including those with femoral cannulation, can be mobilized safely with the use of an interprofessional ambulation protocol. Further evaluation is indicated, including research on clinical outcomes.
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Affiliation(s)
- Kelly Patrick
- Kelly Patrick is a nurse and a cardiothoracic intensive care unit nurse educator, Tampa General Hospital, Tampa, Florida
| | - Anthony Adams
- Anthony Adams is a nurse manager in the cardiothoracic intensive care unit, Anderson Hospital, Cincinnati, Ohio
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Miller AG, Wilson MD, Davies JD, Gentile MA, Thalman JJ, MacIntyre NR. Impact of a Formal Research Committee on Respiratory Therapists' Publications. Respir Care 2021; 66:1229-1233. [PMID: 33947792 PMCID: PMC9994370 DOI: 10.4187/respcare.08601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Presenting research at national and international meetings is an important aspect of the practice of respiratory care. Our department regularly presented abstracts but few projects were written up as manuscripts. We also noted that we did not have a centralized strategy to evaluate individual projects and provide mentorship. To address these challenges, we formed a Research Committee that meets monthly. We hypothesized that the formation of this committee would be associated with an increase in published manuscripts. METHODS We evaluated all original research abstracts authored or co-authored by Duke respiratory therapists presented at the AARC Open Forum between 2009 and 2019. Abstracts were grouped into two time periods; 1) 2009-2013 (before the formation of the research committee) and 2) 2014-2019 (after the formation of the research committee). Abstracts were evaluated based on authors, type of study, patient population, and whether the abstract resulted in a manuscript. Primary outcome was the percentage of abstracts published as manuscripts. RESULTS A total of 56 abstracts were presented by 23 different lead authors, with 16 (29%) published as manuscripts. After formation of the committee, fewer abstracts per year were presented, but these abstracts were more likely to be published as manuscripts (53% vs 18%, P = .02). For abstracts published as manuscripts, there was a significant difference in the type of study before and after committee formation (P = .042), but there were no differences in lead author credentials, senior author credentials, author gender, or patient population. CONCLUSIONS The formation of a research committee was associated with an increase in the percentage of abstracts published as manuscripts.
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Affiliation(s)
| | | | - John D Davies
- Duke University Medical Center, Durham, North Carolina
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Hawkins RB, Mehaffey JH, Charles EJ, Mannem HC, Roeser M. Lung Transplantation for Severe Post-coronavirus Disease 2019 Respiratory Failure. Transplantation 2021; 105:1381-1387. [PMID: 33606480 DOI: 10.1097/tp.0000000000003706] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has resulted in >72 million cases and 1.6 million deaths. End-stage lung disease from COVID-19 is a new and growing entity that may benefit from lung transplant; however, there are limited data on the patient selection, perioperative management, and expected outcomes of transplantation for this indication. METHODS A systematic review of the literature was performed with searches of MEDLINE and Web of Science databases as well as the gray literature. All manuscripts, editorials, commentaries, and gray literature reports of lung transplantation for COVID-related respiratory failure were included. A case from the University of Virginia is described and included in the review. RESULTS A total of 27 studies were included: 11 manuscripts, 5 commentaries, and 11 gray literature reports. The total number of transplantations for COVID-related lung disease was 21. The mean age was 55±12 years, 16 (76%) were male individuals, and the acuity was high, with 85% on extracorporeal membrane oxygenation preoperatively. There was a 95% early survival rate, with 1 additional late death. There is growing histopathologic evidence for permanent structural damage with no replicating virus at the time of transplantation. CONCLUSIONS Bilateral lung transplantation is an effective treatment option with reasonable short-term outcomes for patients with end-stage lung failure secondary to COVID-19. However, specific considerations in this new population require a multidisciplinary approach. As we move into the second wave of the COVID-19 global pandemic, lung transplantation will likely have a growing role in management of these complex patients.
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Affiliation(s)
- Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Eric J Charles
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
| | - Hannah C Mannem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Mark Roeser
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
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Khan IR, Saulle M, Oldham MA, Weber MT, Schifitto G, Lee HB. Cognitive, Psychiatric, and Quality of Life Outcomes in Adult Survivors of Extracorporeal Membrane Oxygenation Therapy: A Scoping Review of the Literature. Crit Care Med 2021; 48:e959-e970. [PMID: 32886470 DOI: 10.1097/ccm.0000000000004488] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To perform a scoping literature review of cognitive, psychiatric, and quality of life outcomes in adults undergoing extracorporeal membrane oxygenation for any indication. DATA SOURCES We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, and PsycINFO from inception to June 2019. STUDY SELECTION Observational studies, clinical trials, qualitative studies, and case series with at least 10 adult subjects were included for analysis. Outcomes of interest consisted of general or domain-specific cognition, psychiatric illness, and quality of life measures that included both mental and physical health. DATA EXTRACTION Study selection, data quality assessment, and interpretation of results were performed by two independent investigators in accordance with the PRISMA statement. DATA SYNTHESIS Twenty-two articles were included in this review. Six described cognitive outcomes, 12 described psychiatric outcomes of which two were qualitative studies, and 16 described quality of life outcomes. Cognitive impairment was detected in varying degrees in every study that measured it. Three studies examined neuroimaging results and found neurologic injury to be more frequent in venoarterial versus venovenous extracorporeal membrane oxygenation, but described a variable correlation with cognitive impairment. Rates of depression, anxiety, and post-traumatic stress disorder were similar to other critically ill populations and were related to physical disability after extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survivors' physical quality of life was worse than population norms but tended to improve with time, while mental quality of life did not differ significantly from the general population. Most studies did not include matched controls and instead compared outcomes to previously published values. CONCLUSIONS Extracorporeal membrane oxygenation survivors experience cognitive impairment, psychiatric morbidity, and worse quality of life compared with the general population and similar to other survivors of critical illness. Physical disability in extracorporeal membrane oxygenation patients plays a significant role in psychiatric morbidity. However, it remains unclear if structural brain injury plays a role in these outcomes and whether extracorporeal membrane oxygenation causes secondary brain injury.
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Affiliation(s)
- Imad R Khan
- Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Michael Saulle
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Miriam T Weber
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Hochang B Lee
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
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Orizondo RA, Omecinski KS, May AG, Dhamotharan V, Frankowski BJ, Burgreen GW, Ye SH, Kocyildirim E, Sanchez PG, D’Cunha J, Wagner WR, Federspiel WJ. Month-long Respiratory Support by a Wearable Pumping Artificial Lung in an Ovine Model. Transplantation 2021; 105:999-1007. [PMID: 33031226 PMCID: PMC8024407 DOI: 10.1097/tp.0000000000003481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A wearable artificial lung could improve lung transplantation outcomes by easing implementation of physical rehabilitation during long-term pretransplant respiratory support. The Modular Extracorporeal Lung Assist System (ModELAS) is a compact pumping artificial lung currently under development. This study evaluated the long-term in vivo performance of the ModELAS during venovenous support in awake sheep. Feedback from early trials and computational fluid dynamic analysis guided device design optimization along the way. METHODS The ModELAS was connected to healthy sheep via a dual-lumen cannula in the jugular vein. Sheep were housed in a fixed-tether pen while wearing the device in a holster during support. Targeted blood flow rate and support duration were 2-2.5 L/min and 28-30 days, respectively. Anticoagulation was maintained via systemic heparin. Device pumping and gas exchange performance and hematologic indicators of sheep physiology were measured throughout support. RESULTS Computational fluid dynamic-guided design modifications successfully decreased pump thrombogenicity from initial designs. For the optimized design, 4 of 5 trials advancing past early perioperative and cannula-related complications lasted the full month of support. Blood flow rate and CO2 removal in these trials were 2.1 ± 0.3 L/min and 139 ± 15 mL/min, respectively, and were stable during support. One trial ended after 22 days of support due to intradevice thrombosis. Support was well tolerated by the sheep with no signs of hemolysis or device-related organ impairment. CONCLUSIONS These results demonstrate the ability of the ModELAS to provide safe month-long support without consistent deterioration of pumping or gas exchange capabilities.
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Affiliation(s)
- Ryan A. Orizondo
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Medicine, University of Pittsburgh
- Department of Bioengineering, University of Pittsburgh
| | - Katelin S. Omecinski
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Bioengineering, University of Pittsburgh
| | - Alexandra G. May
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Chemical and Petroleum Engineering, University of Pittsburgh
| | - Vishaal Dhamotharan
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Bioengineering, University of Pittsburgh
| | | | - Greg W. Burgreen
- Computational Fluid Dynamics Group, Center for Advanced Vehicular Systems, Mississippi State University
| | - Sang-Ho Ye
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Surgery, University of Pittsburgh
| | - Ergin Kocyildirim
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Cardiothoracic Surgery, Children’s Hospital of Pittsburgh
| | - Pablo G. Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center
| | - Jonathan D’Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center
| | - William R. Wagner
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Bioengineering, University of Pittsburgh
- Department of Chemical and Petroleum Engineering, University of Pittsburgh
- Department of Surgery, University of Pittsburgh
| | - William J. Federspiel
- McGowan Institute for Regenerative Medicine, University of Pittsburgh
- Department of Bioengineering, University of Pittsburgh
- Department of Chemical and Petroleum Engineering, University of Pittsburgh
- Department of Critical Care Medicine, University of Pittsburgh Medical Center
- Clinical and Translational Science Institute, University of Pittsburgh
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Nasir BS, Klapper J, Hartwig M. Lung Transplant from ECMO: Current Results and Predictors of Post-transplant Mortality. CURRENT TRANSPLANTATION REPORTS 2021; 8:140-150. [PMID: 33842193 PMCID: PMC8021937 DOI: 10.1007/s40472-021-00323-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
Purpose of Review We examined data from the last 5 years describing extracorporeal life support (ECLS) as a bridge to lung transplantation. We assessed predictors of survival to transplantation and post-transplant mortality. Recent Findings The number of lung transplants performed worldwide is increasing. This is accompanied by an increase in the type of patients being transplanted, including sicker patients with more advanced disease. Consequently, there is an increase in the need for bridging strategies, with varying success. Several predictors of failure have been identified. Major risk factors include retransplantation, other organ dysfunction, and deconditioning. Summary ECLS is a risky strategy but necessary for patients who would otherwise die if not bridged to transplantation. The presence of predictors for failure is not a contraindication for bridging. However, major risk factors should be approached cautiously. Other, more minor risk factors may be considered acceptable. More importantly, the strategy should be individualized for each patient to achieve the best possible outcomes.
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Affiliation(s)
- Basil S Nasir
- Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, 1000 rue Saint-Denis, Montreal, Quebec, H2X 0C1 Canada
| | - Jacob Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Medical Center, Durham, NC USA
| | - Matthew Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Medical Center, Durham, NC USA
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Ohsumi A, Date H. Perioperative circulatory support for lung transplantation. Gen Thorac Cardiovasc Surg 2021; 69:631-637. [PMID: 33666866 PMCID: PMC7934122 DOI: 10.1007/s11748-021-01610-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has recently replaced cardiopulmonary bypass (CPB) as the preferred option for providing circulatory support during lung transplantation. This review aimed to summarize the previous data and to address the relative use of ECMO and CPB during lung transplantation. METHODS The database was searched in PubMed (Medline) using the following keywords: lung transplantation, extracorporeal membrane oxygenation, and cardiopulmonary bypass, for all relevant reports which were written in English and were published between 2000 and 2020. REVIEW Several reports have revealed that intraoperative use of ECMO is associated with lower blood product transfusion requirements, shorter ventilator support, and shorter length of hospital stay. During recent years, preoperative ECMO has also been used with favorable outcomes as a bridge to lung transplantation in critically ill patients. CONCLUSIONS The use of ECMO during lung transplantation seems to reduce postoperative complications and improve short-term outcomes, relative to CPB. However, additional data should be collected through large multicenter randomized controlled trials. Furthermore, preoperative ECMO as a bridge to lung transplantation appears to provide favorable outcomes, although additional data are also needed from experienced transplant centers.
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Affiliation(s)
- Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Sunder T. Extracorporeal membrane oxygenation and lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 37:327-337. [PMID: 33487892 PMCID: PMC7813619 DOI: 10.1007/s12055-020-01099-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
The use of extracorporeal membrane oxygenation has had a positive impact on the outcomes after lung transplantation. Extracorporeal membrane oxygenation has a role in all phases of lung transplantation-preoperative, intraoperative, and postoperative periods. It serves as a bridge to transplantation in appropriate patients awaiting lung transplantation. Extracorporeal membrane oxygenation is used as a preferred method of cardiopulmonary support in some centres during implantation; and, after lung transplantation, it can be used to salvage the implanted lung in cases of severe primary graft dysfunction or as a planned extension of intraoperative extracorporeal membrane oxygenation onto the postoperative period. It has now gained acceptance as a mandatory tool in most lung transplant units. This article reviews the history of extracorporeal membrane oxygenation and lung transplantation, their subsequent development, and the current use of extracorporeal membrane oxygenation during lung transplantation. Our institutional practice and experience are described. The implications of the current global coronavirus disease pandemic on extracorporeal membrane oxygenation and lung transplantation are also briefly discussed.
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Freiberger D, Gould Delaney A, Forbes P, Manley D, Visner GA. Pediatric lung transplant: Correlation of pretransplant condition with post-transplant outcomes. Pediatr Transplant 2021; 25:e13889. [PMID: 33118294 DOI: 10.1111/petr.13889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/20/2020] [Accepted: 09/28/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND It is generally accepted that patients who have greater functional capacity are better candidates for lung transplantation. Accurate assessment of physical condition is important in identifying appropriate candidates for transplant. The focus of this study was to determine which measures of pretransplant physical condition correlate with positive post-transplant outcomes in children undergoing lung transplant. METHODS A retrospective chart review was done on 44 patients, ages 5 to 21 years. The pretransplant data collected included functional status, 6MWT, ambulatory status, and mechanical support. Post-transplant outcome data included time on the ventilator, days in the ICU, length of hospitalization, and 12-month survival. RESULTS Results were analyzed using Fisher exact and Kruskal-Wallis tests. Patients with limited ambulation had more days in the ICU compared to the most ambulatory group (P = .043). Patients independent or needing some help with ADL had less time on the ventilator compared to patients needing total help. (P = .014). Patients with 6MWT result greater than 500' had fewer ICU days (P = .044) and marginally better 12-month survival (P = .057). The 12-month survival of children needing invasive ventilatory support pretransplant was not significantly worse than those who did not; however, they required significantly more time on the ventilator (P = .004), days in ICU (P = .013), and longer hospitalization. DISCUSSION This study demonstrated that pretransplant physical condition affects post-transplant outcomes in children. Measures associated with positive post-transplant outcomes were identified and could be beneficial in determining which patients are optimal candidates for lung transplant.
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Affiliation(s)
- Dawn Freiberger
- Division of Pulmonary Medicine, Pediatric Transplant Center, Boston Children's Hospital, Boston, MA, USA
| | - Anne Gould Delaney
- Division of Pulmonary Medicine, Pediatric Transplant Center, Boston Children's Hospital, Boston, MA, USA
| | - Peter Forbes
- Division of Pulmonary Medicine, Pediatric Transplant Center, Boston Children's Hospital, Boston, MA, USA
| | - Donna Manley
- Division of Pediatric Allergy and Pulmonary, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Pediatric Transplant Center, Boston Children's Hospital, Boston, MA, USA
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Taniguchi H, Ikeda T, Takeuchi I, Ichiba S. Iliopsoas Hematoma in Patients Undergoing Venovenous ECMO. Am J Crit Care 2021; 30:55-63. [PMID: 33385201 DOI: 10.4037/ajcc2021351] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Iliopsoas hematoma occasionally occurs in patients receiving anticoagulation therapy. It may be a life-threatening complication and can cause disseminated intravascular coagulation, which could develop into abdominal compartment syndrome. The incidence of and factors associated with iliopsoas hematoma during venovenous extracorporeal membrane oxygenation (ECMO) have not been well studied. OBJECTIVES To describe the incidence of iliopsoas hematoma and associated factors among patients undergoing venovenous ECMO. METHODS A retrospective cohort study was conducted at Nippon Medical School Hospital from April 2015 to October 2018. All patients (>18 years old) with iliopsoas hematoma received a diagnosis based on computed tomography. RESULTS During the study period, 54 patients were supported with venovenous ECMO. Iliopsoas hematoma occurred in 8 of those patients (15%), none of whom had disseminated intravascular coagulopathy or abdominal compartment syndrome develop. Univariate analysis indicated that management of ECMO while the patient was awake and mobilization beyond sitting on the edge of the bed were significantly different (P < .05) in patients with and patients without iliopsoas hematoma. Mortality, however, did not differ significantly between the 2 groups. CONCLUSIONS Our findings emphasize that recognizing factors associated with iliopsoas hematoma and detecting them early are crucial during venovenous ECMO in order to treat patients with iliopsoas hematoma appropriately.
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Affiliation(s)
- Hayato Taniguchi
- Hayato Taniguchi is an assistant professor, Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan, and Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Tokuji Ikeda
- Tokuji Ikeda is an assistant professor, Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital
| | - Ichiro Takeuchi
- Ichiro Takeuchi is a professor, Advanced Critical Care and Emergency Center, Yokohama City University Medical Center
| | - Shingo Ichiba
- Shingo Ichiba is a professor, Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital
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Mayer KP, Jolley SE, Etchill EW, Fakhri S, Hoffman J, Sevin CM, Zwischenberger JB, Rove JY. Long-term recovery of survivors of coronavirus disease (COVID-19) treated with extracorporeal membrane oxygenation: The next imperative. ACTA ACUST UNITED AC 2020; 5:163-168. [PMID: 34173554 PMCID: PMC7687357 DOI: 10.1016/j.xjon.2020.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Ky
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colo
| | - Eric W Etchill
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Shoaib Fakhri
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colo
| | - Jordan Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, Vanderbilt University, Nashville, Tenn
| | - Carla M Sevin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Joseph B Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, College of Medicine, University of Kentucky, Lexington, Ky
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colo
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Abstract
Children with end-stage lung failure awaiting lung transplant would benefit from improvements in artificial lung technology allowing for wearable pulmonary support as a bridge-to-transplant therapy. In this work, we designed, fabricated, and tested the Pediatric MLung-a dual-inlet hollow fiber artificial lung based on concentric gating, which has a rated flow of 1 L/min, and a pressure drop of 25 mm Hg at rated flow. This device and future iterations of the current design are designed to relieve pulmonary arterial hypertension, provide pulmonary support, reduce ventilator-associated injury, and allow for more effective therapy of patients with end-stage lung disease, including bridge-to-transplant treatment.
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Habertheuer A, Richards T, Sertic F, Molina M, Vallabhajosyula P, Suzuki Y, Diagne D, Cantu E, Sultan I, Crespo MM, Bermudez CA. Stratification Risk Analysis in Bridging Patients to Lung Transplant on ECMO: The STABLE Risk Score. Ann Thorac Surg 2020; 110:1175-1184. [DOI: 10.1016/j.athoracsur.2020.03.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/26/2020] [Accepted: 03/23/2020] [Indexed: 01/10/2023]
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Anticoagulation for Extracorporeal Membrane Oxygenation: Between the Rock and the Hard Place. Crit Care Med 2020; 48:264-266. [PMID: 31939802 DOI: 10.1097/ccm.0000000000004157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Chan EG, Chan PG, Harano T, Sanchez PG. Transition of femoral-jugular to dual-stage left subclavian without discontinuation of extracorporeal membrane oxygenation. J Card Surg 2020; 35:2794-2797. [PMID: 32720393 DOI: 10.1111/jocs.14881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technology that has allowed further cardiopulmonary support in the setting of respiratory failure refractory to mechanical ventilation. While it has evolved since its first description, one area of improvement continues to be its implementation. With advancements in cannulation techniques, in recent years, there has been a plethora of new cannulas that has been introduced in the market. For urgent venous-venous cannulation, the right internal jugular vein along with either femoral veins remain the most utilized strategy due to minimal need for imaging support. This allows for safe bedside cannulation. However, as the number of days of ECMO support continue to increase, transitioning to a cannulation strategy that is easier to ambulate with and more comfortable is preferred. Therefore, we describe a method for transitioning from right jugular-femoral cannulation to left subclavian placement of the Crescent Dual-Lumen catheter without interrupting ECMO support.
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Affiliation(s)
- Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patrick G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Orozco-Hernandez EJ, Melnikoff B, Lusby M, Tallaj J, Hoopes CW. Peripheral femoral venoarterial extracorporeal membrane oxygenation as bridge to heart-lung transplant omne iter incipit primus. J Card Surg 2020; 35:2077-2080. [PMID: 32652726 DOI: 10.1111/jocs.14779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Heart-lung transplant (HLT) is a widely accepted modality for certain patients with advanced and refractory cardiopulmonary disease. Some of these patients are critically ill on the transplant waiting list, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be used as a bridge to transplantation. Although the experience with ECMO as a bridge to lung transplant is promising, there is limited evidence to use ECMO as a bridge to HLT. Femoral cannulation remains a concern for ambulation given the risk of bleeding and cannula complications despite studies reporting its safety. We present a case of a 56-year-old male with interstitial lung disease and severe secondary pulmonary hypertension, who was successfully bridged to HLT with ambulatory femoral VA-ECMO.
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Affiliation(s)
- Erik J Orozco-Hernandez
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brett Melnikoff
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Megan Lusby
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jose Tallaj
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles W Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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