1
|
Sud S, Fan E, Adhikari NKJ, Friedrich JO, Ferguson ND, Combes A, Guerin C, Guyatt G. Comparison of venovenous extracorporeal membrane oxygenation, prone position and supine mechanical ventilation for severely hypoxemic acute respiratory distress syndrome: a network meta-analysis. Intensive Care Med 2024; 50:1021-1034. [PMID: 38842731 DOI: 10.1007/s00134-024-07492-7] [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] [Received: 02/03/2024] [Accepted: 05/13/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. METHODS We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. RESULTS Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59-0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57-0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66-0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63-1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72-1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. CONCLUSIONS In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.
Collapse
Affiliation(s)
- Sachin Sud
- Division of Critical Care, Department of Medicine, Trillium Health Center, University of Toronto, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
- Institute of Better Health, Trillium Health Partners, Mississauga, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France
| | - Claude Guerin
- Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Université de Lyon, Lyon, France
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| |
Collapse
|
2
|
Jørgensen VL, Adelsten J, Christensen S, Nielsen DV, Eschen CT, Sørensen HM, Sørensen M, Madsen SA, Gjedsted J, Pedersen FM, Nielsen J, Grønlykke L. The use of prone position ventilation in Danish patients with COVID-19-induced severe acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation: A nationwide cohort study with focus on pulmonary effects. Acta Anaesthesiol Scand 2024. [PMID: 38932581 DOI: 10.1111/aas.14481] [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: 08/08/2023] [Revised: 05/25/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Prone position ventilation (PPV) is recommended for patients with COVID-19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V-V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance. METHODS This study was a nationwide retrospective analysis of all COVID-19 patients in Denmark from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported. RESULTS Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within-patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course. CONCLUSION Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance.
Collapse
Affiliation(s)
- Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Janne Adelsten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Dorthe Viemose Nielsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Tofte Eschen
- Department of Anaesthesiology and Intensive Care, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hasse Møller Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Møller Pedersen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jonas Nielsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
3
|
Lucchini A, Villa M, Maino C, Alongi F, Fiorica V, Lipani B, Ponzetta G, Vigo V, Rezoagli E, Giani M. The occurrence of pressure injuries and related risk factors in patients undergoing extracorporeal membrane oxygenation for respiratory failure: A retrospective single centre study. Intensive Crit Care Nurs 2024; 82:103654. [PMID: 38387296 DOI: 10.1016/j.iccn.2024.103654] [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] [Received: 09/28/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Limited data is available regarding the incidence of pressure injuries in patients who have undergone Extracorporeal Membrane Oxygenation (ECMO), a life-saving technique that provides respiratory support for hypoxemia that does not respond to conventional treatment. AIM To assess the incidence of pressure injuries and identify the risk factors in Acute Respiratory Distress Syndrome patients receiving ECMO. METHODS A retrospective observational study utilizing prospectively collected data was performed in an Italian intensive care unit, between 1 January 2012 and 30 April 2022 enrolling all consecutive patients with Acute Respiratory Distress Syndrome who underwent ECMO. RESULTS One hundred patients were included in this study. 67 patients (67%) developed pressure injuries during their intensive care unit stay, with a median of 2 (1-3) sites affected. The subgroup of patients with pressure injuries was more hypoxic before ECMO implementation, received more frequent continuous renal replacement therapy and prone positioning, and showed prolonged ECMO duration, intensive care unit and hospital length of stay compared to patients without pressure injuries. The logistic model demonstrated an independent association between the pO2/FiO2 ratio prior to ECMO initiation, the utilization of the prone positioning during ECMO, and the occurrence of pressure injuries. CONCLUSIONS The incidence of pressure injuries was elevated in patients with Adult Respiratory Distress Syndrome who received ECMO. The development of pressure injuries was found to be independently associated with hypoxemia before ECMO initiation and the utilization of prone positioning during ECMO. IMPLICATIONS FOR CLINICAL PRACTICE Patients who require ECMO for respiratory failure are at a high risk of developing pressure injuries. To ensure optimal outcomes during ECMO implementation and treatment, it is vital to implement preventive measures and to closely monitor skin health in at-risk areas.
Collapse
Affiliation(s)
- Alberto Lucchini
- Direction of Health and Social Professions, General Adult and Pediatric Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori - Monza - University of Milano-Bicocca, Italy.
| | - Marta Villa
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Clara Maino
- Direction of Health and Social Professions, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Francesca Alongi
- Cardiologic Intensive Care Unit, ASST GOM Niguarda, Milano, Italy
| | | | - Barbara Lipani
- General ICU - A.O.U.I. Verona Policlinico G.B. Rossi, Italy
| | - Giuseppe Ponzetta
- Centro Sanitario Bregaglia - Pronto Soccorso, Promontogno, Svizzera, Switzerland.
| | - Veronica Vigo
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Marco Giani
- Department of Emergency and Intensive Care, General Adult and Pediatric Intensive Care Unit Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| |
Collapse
|
4
|
de Jongh MC, Bax M, Ayan K, Akin S. Proning the extracorporeal membrane oxygenation plus Impella: a case report. Eur Heart J Case Rep 2024; 8:ytae165. [PMID: 38633423 PMCID: PMC11022646 DOI: 10.1093/ehjcr/ytae165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 03/17/2024] [Accepted: 03/28/2024] [Indexed: 04/19/2024]
Abstract
Background The prone position is recommended as supportive therapy in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). However, little is known about prone position ventilation in patients with cardiogenic shock supported by extracorporeal membrane oxygenation (ECMO) plus Impella (ECPELLA) developing ARDS. Case summary A 66-year-old man with severe left ventricular dysfunction was admitted to a non-academic ECMO centre for a high-risk coronary artery bypass grafting. He developed post-cardiotomy shock needing ECMO support. To improve left ventricular unloading, an Impella was inserted 2 days later. One day later, he developed ARDS and needed prone position ventilation with ECPELLA in situ. After 4 weeks, he was discharged from the intensive care unit. Discussion Previous studies demonstrated that prone positioning could help avoid an additional venous cannula in veno-arterial ECMO patients, which is associated with mechanical complications. In this case, there was a promising role for unloading the left ventricle with Impella during veno-arterial ECMO and, for proning, the patient with cardiogenic shock developing ARDS during ECMO support without the need for an extra venous cannula.
Collapse
Affiliation(s)
- Marjolein C de Jongh
- Department of Intensive Care, Haga Teaching Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands
| | - Matthijs Bax
- Department of Cardiology, Haga Teaching Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands
| | - Khalil Ayan
- Department of Cardiothoracic Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Sakir Akin
- Department of Intensive Care, Haga Teaching Hospital, Els Borst-Eilersplein 275, The Hague 2545 AA, The Netherlands
| |
Collapse
|
5
|
Binda F, Marelli F, Galazzi A, Gambazza S, Vinci E, Roselli P, Adamini I, Laquintana D. Pressure ulcers after prone positioning in patients undergoing extracorporeal membrane oxygenation: A cross-sectional study. Nurs Crit Care 2024; 29:65-72. [PMID: 36740588 DOI: 10.1111/nicc.12889] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/23/2022] [Accepted: 01/13/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications. AIM To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno-venous ECMO. STUDY DESIGN This cross-sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno-venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model. RESULTS In the study period, 114 patients were treated with veno-venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro-femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%-72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5-3.6, p = .532). CONCLUSIONS Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence-based care to prevent such pressure injuries in patients undergoing ECMO. RELEVANCE TO CLINICAL PRACTICE The combination of prone positioning and ECMO shows few life-threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.
Collapse
Affiliation(s)
- Filippo Binda
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Marelli
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Galazzi
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simone Gambazza
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Vinci
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Roselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ileana Adamini
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Laquintana
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
6
|
Adelsten J, Grønlykke L, Pedersen FM, Madsen SA, Sørensen M, Eschen CT, Møller Sørensen PH, Gjedsted J, Nielsen DV, Christensen S, Nielsen J, Jørgensen VL. Use of prone position ventilation in patients with COVID-19 induced severe ARDS supported with V-V ECMO: A danish cohort study with focus on adverse events. Perfusion 2023:2676591231198798. [PMID: 37787741 DOI: 10.1177/02676591231198798] [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: 10/04/2023]
Abstract
INTRODUCTION Prone position ventilation (PPV) of patients with adult respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) may improve oxygenation and alveolar recruitment and is recommended when extensive dorsal consolidations are present, but only few data regarding adverse events (AE) related to PPV in this group of patients have been published. METHODS Nationwide retrospective analysis of 68 COVID-19 patients admitted from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. The number of patients treated with PPV, number of PPV-events, timing, the time spent in prone position, number and causes of AE are reported. Causes to stop the PPV regimen and risk factors for AE were explored. RESULTS 44 out of 68 patients were treated with PPV, and 220 PPV events are evaluated. AE were identified in 99 out of 220 (45%) PPV events and occurred among 31 patients (71%). 1 fatal PPV related AE was registered. Acute supination occurred in 19 events (9%). Causes to stop the PPV regimen were almost equally distributed between effect (weaned from ECMO), no effect, death (of other reasons) and AE. Frequent causes of AE were pressures sores and ulcers, hypoxia, airway related and ECMO circuit related. Most AE occurred during patients first or second PPV event. CONCLUSIONS PPV treatment was found to carry a high incidence of PPV related AE in these patients. Causes and preventive measures to reduce occurrence of PPV related AE during V-V ECMO support need further exploration.
Collapse
Affiliation(s)
- Janne Adelsten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Møller Pedersen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Camilla Tofte Eschen
- Department of Anaesthesiology and Intensive Care, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Peter Hasse Møller Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorthe Viemose Nielsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Nielsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
7
|
Huai J, Ye X. Impact of prone positioning duration on the outcome of patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: A meta-analysis. Heliyon 2022; 8:e12320. [PMID: 36568680 PMCID: PMC9764689 DOI: 10.1016/j.heliyon.2022.e12320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/13/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose Research has shown that prone positioning (PP) improves the survival of patients receiving venovenous extracorporeal membrane oxygenation (V-V ECMO) for acute respiratory distress syndrome (ARDS). However, the reported impact of PP duration on the outcome of V-V ECMO patients with ARDS varies across studies. Methods A meta-analysis approach was used to identify studies that investigated the impact of PP duration on the outcome of ARDS patients who were treated with V-V ECMO; the following databases were used: MEDLINE, Embase, Wanfang, and the China National Knowledge Infrastructure. The primary outcome was cumulative survival. Secondary outcomes were length of stay in an intensive care unit, exchange of arterial blood gases, and adverse events. Results A total of 8 studies were included in the final meta-analysis. Patients with longer duration of PP (≥12 h) had a longer survival period (risk ratio: 1.24; 95% confidence interval: 1.00, 1.54]) than those with PP < 12 h. There was no evidence of publication bias across the studies. Conclusion Our results imply that a longer duration of PP ≥ 12 h might improve the outcome of patients with ARDS who receive V-V ECMO therapy.
Collapse
Affiliation(s)
- Jiaping Huai
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, 321000, China
| | - Xiaohua Ye
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, 321000, China,Corresponding author.
| |
Collapse
|
8
|
Zhang H, Liu Z, Shu H, Yu Y, Yang X, Li R, Xu J, Zou X, Shang Y. Prone positioning in ARDS patients supported with VV ECMO, what we should explore? J Intensive Care 2022; 10:46. [PMID: 36195935 PMCID: PMC9531855 DOI: 10.1186/s40560-022-00640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS), a prevalent cause of admittance to intensive care units, is associated with high mortality. Prone positioning has been proven to improve the outcomes of moderate to severe ARDS patients owing to its physiological effects. Venovenous extracorporeal membrane oxygenation (VV ECMO) will be considered in patients with severe hypoxemia. However, for patients with severe hypoxemia supported with VV ECMO, the potential effects and optimal strategies of prone positioning remain unclear. This review aimed to present these controversial questions and highlight directions for future research. Main body The clinically significant benefit of prone positioning and early VV ECMO alone was confirmed in patients with severe ARDS. However, a number of questions regarding the combination of VV ECMO and prone positioning remain unanswered. We discussed the potential effects of prone positioning on gas exchange, respiratory mechanics, hemodynamics, and outcomes. Strategies to achieve optimal outcomes, including indications, timing, duration, and frequency of prone positioning, as well as the management of respiratory drive during prone positioning sessions in ARDS patients receiving VV ECMO, are challenging and controversial. Additionally, whether and how to implement prone positioning according to ARDS phenotypes should be evaluated. Lung morphology monitored by computed tomography, lung ultrasound, or electrical impedance tomography might be a potential indication to make an individualized plan for prone positioning therapy in patients supported with VV ECMO. Conclusion For patients with ARDS supported with VV ECMO, the potential effects of prone positioning have yet to be clarified. Ensuring an optimal strategy, especially an individualized plan for prone positioning therapy during VV ECMO, is particularly challenging and requires further research.
Collapse
Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| |
Collapse
|
9
|
Chen Z, Li M, Gu S, Huang X, Xia J, Ye Q, Zheng J, Zhan Q, Wang C. Effect of prone position in patients with acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation: a retrospective cohort study. BMC Pulm Med 2022; 22:234. [PMID: 35710365 PMCID: PMC9202669 DOI: 10.1186/s12890-022-02026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background The application of prone position (PP) in acute respiratory distress syndrome (ARDS) supported by venovenous extracorporeal membrane oxygenation (VV-ECMO) is controversial.
Objectives To evaluate the safety and efficacy of application of PP during VV-ECMO in patients with ARDS.
Methods This was a single-center, retrospective study of patients who met the Berlin definition of ARDS, and were supported with VV-ECMO. We divided the patients into two groups. The prone group included patients who were supported by VV-ECMO, and experienced at least one period of PP, while those without PP during VV-ECMO were defined as the supine group. Propensity score matching (PSM) at a ratio of 1:1 was introduced to minimize potential confounders. The primary outcomes were the complications of PP and the change of arterial oxygen pressure/fraction of the inspiration (PaO2/FiO2) ratio after PP. The secondary outcomes were hospital survival, ICU survival, and ECMO weaning rate. Results From April 2013 to October 2020, a total of 91 patients met the diagnostic criteria of ARDS who were supported with ECMO. 38 patients (41.8%) received at least one period of PP during ECMO, while 53 patients (58.2%) were maintained in supine position during ECMO. 22 minor complications were reported in the prone group and major complications were not found. The other ECMO-related complications were similar between two groups. The PaO2/FiO2 ratio significantly improved after PP compared with before (174.50 (132.40–228.25) mmHg vs. 158.00 (122.93–210.33) mmHg, p < 0.001). PSM selected 25 pairs of patients with similar characteristics. Hospital survival or ICU survival did not differ between the two groups (40% vs. 28%, p = 0.370; 40% vs. 32%, p = 0.556). Significant difference of ECMO weaning rate between two groups was not found (56% vs. 32%, p = 0.087). Conclusions PP during VV-ECMO was safe and could improve oxygenation. A large-scale and well-designed RCT is needed in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02026-7.
Collapse
Affiliation(s)
- Ziying Chen
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Min Li
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Sichao Gu
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Xu Huang
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Jingen Xia
- Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Qinghua Ye
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Jiangnan Zheng
- Department of Pulmonary and Critical Care Medicine, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, People's Republic of China
| | - Qingyuan Zhan
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China. .,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China. .,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China. .,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China.
| | - Chen Wang
- Peking University China-Japan Friendship School of Clinical Medicine, No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029, People's Republic of China.,Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| |
Collapse
|
10
|
Papazian L, Schmidt M, Hajage D, Combes A, Petit M, Lebreton G, Rilinger J, Giani M, Le Breton C, Duburcq T, Jozwiak M, Wengenmayer T, Roux D, Parke R, Loundou A, Guervilly C, Boyer L. Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med 2022; 48:270-280. [PMID: 35037993 PMCID: PMC8762989 DOI: 10.1007/s00134-021-06604-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022]
Abstract
Purpose Previous studies support the potential efficacy of venovenous extracorporeal membrane oxygenation (vvECMO) for improving survival in severe acute respiratory distress syndrome (ARDS) cases. Prone positioning (PP) has been shown to improve the outcomes of moderate-to-severe ARDS patients. Few studies and no randomized controlled trials have evaluated the effect of PP performed in ECMO patients. Methods We performed a systematic review and meta-analysis examining the effect of prone positioning for ARDS patients receiving vvECMO on survival. All authors were contacted to obtain complementary information not mentioned in the original articles. The main objective was to compare 28-day survival in vvECMO patients with PP to vvECMO patients without PP (controls). Results Thirteen studies with a combined population of 1836 patients satisfied the inclusion criteria. PP was associated with a significant improvement in 28-day survival (503 survivors among 681 patients in the PP group [74%; 95% CI 71–77] vs. 450 survivors among 770 patients in the control group [58%, 95% CI 55–62]; RR 1.31 [95% CI 1.21–1.41]; I2 22% [95% CI 0–62%]; P < 0.0001). Survival was also improved in terms of other endpoints (60-day survival, 90-day survival, ICU survival, and hospital survival). In contrast, the duration of mechanical ventilation was increased in vvECMO patients with PP (mean difference 11.4 days [95% CI 9.2–13.5]; 0.64 [95% CI 0.50–0.78]; I2 8%; P < 0.0001). Conclusion According to this meta-analysis, survival was improved when prone positioning was used in ARDS patients receiving vvECMO. The impact of this combination on survival should be investigated in prospective randomized controlled trials. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06604-x.
Collapse
Affiliation(s)
- Laurent Papazian
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Hôpital Nord, Chemin Des Bourrely, 13015, Marseille, France.
- Aix-Marseille Université, Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, 13005, Marseille, France.
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, 75013, Paris, France
| | - Alain Combes
- Sorbonne Université, GRC 30, RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Matthieu Petit
- Sorbonne Université, GRC 30, RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Médecine Intensive Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Cardiovascular and Thoracic Surgery, Institut de Cardiologie, AP-HP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marco Giani
- Department of Emergency and Intensive Care, School of Medicine and Surgery, University of Milano-Bicocca, ASST Monza, Monza, Italy
| | - Camille Le Breton
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive Réanimation, 92700, Colombes, France
- Faculté de Santé, Université de Paris, UFR de Médecine, 75006, Paris, France
| | | | - Mathieu Jozwiak
- CHU de Nice, Hôpital Archet 1, Médecine Intensive Réanimation, 06200, Nice, France
- Equipe 2 CARRES, UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Damien Roux
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive Réanimation, 92700, Colombes, France
- Faculté de Santé, Université de Paris, UFR de Médecine, 75006, Paris, France
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Anderson Loundou
- CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005, Marseille, France
| | - Christophe Guervilly
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Hôpital Nord, Chemin Des Bourrely, 13015, Marseille, France
- Aix-Marseille Université, Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, 13005, Marseille, France
| | - Laurent Boyer
- CEReSS-Health Service Research and Quality of Life Center, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005, Marseille, France
| |
Collapse
|
11
|
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
Collapse
Affiliation(s)
- Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CibeRes), Madrid, Spain.
| | - Andrés Pacheco
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marina García-de-Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Departament de Medicina, Universitat Autònma de Barcelona, Bellatera, Spain
| |
Collapse
|
12
|
Poon WH, Ramanathan K, Ling RR, Yang IX, Tan CS, Schmidt M, Shekar K. Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care 2021; 25:292. [PMID: 34384475 PMCID: PMC8358249 DOI: 10.1186/s13054-021-03723-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/03/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Prone positioning (PP) improves oxygenation and respiratory mechanics and is associated with lower mortality in patients with moderate to severe acute respiratory distress syndrome (ARDS). Despite this, some patients develop refractory hypoxemia and hypercapnia requiring venovenous extracorporeal membrane oxygenation (VV ECMO) support and are usually cared for in supine position. The physiologic and outcome benefits of routine PP of patients during VV ECMO remains unclear. Hence, we conducted the systematic review and meta-analysis to evaluate the outcome benefits of PP for patients with ARDS being treated with VV ECMO. METHODS After registration with PROSPERO (CRD42020199723), MEDLINE, EMBASE, Scopus and Cochrane databases were searched for relevant studies that reported PP in more than 10 adult patients supported with VV ECMO from origin to 1 March 2021. Studies were reviewed for quality using appropriate Joanna Briggs Institute (JBI) checklists, and certainty of evidence was assessed using the GRADE approach. The random-effects model (DerSimonian and Laird) was used. The primary outcome of interest was cumulative survival. Secondary outcomes were intensive care unit length of stay (ICU LOS) and ECMO duration. Changes in arterial blood gas (ABG) values, ventilator mechanics and complication rates were also studied. RESULTS Of 812 potentially relevant publications, 12 studies (640 patients) met our inclusion criteria. Due to overlapping study populations, 11 studies were included in the final meta-analysis. Cumulative survival in patients that underwent PP was 57% (95% CI 41.9-71.4, high certainty). Patients that underwent PP had longer ICU LOS (+ 14.5 days, 95% CI 3.4-25.7, p = 0.01) and ECMO duration (+ 9.6 days, 95% CI 5.5-13.7, p < 0.0001). After PP, patients had significantly higher PaO2/FiO2 ratio, lower PaCO2 and reduced ventilator driving pressure, and no major complications were reported. CONCLUSIONS PP during VV ECMO appears safe with a cumulative survival of 57% and may result in longer ECMO runs and ICU LOS. However, evidence from appropriately designed randomized trials is needed prior to widespread adoption of PP on VV ECMO.
Collapse
Affiliation(s)
- Wynne Hsing Poon
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
- University of Queensland, Brisbane, Australia.
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Isabelle Xiaorui Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire aigüE, AP-HP, Hôpital de la Pitié Salpêtrière, 75013, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
- Bond University, Gold Coast, QLD, Australia
| |
Collapse
|
13
|
Prone Positioning during Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome. A Multicenter Cohort Study and Propensity-matched Analysis. Ann Am Thorac Soc 2021; 18:495-501. [DOI: 10.1513/annalsats.202006-625oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
14
|
Chaplin H, McGuinness S, Parke R. A single-centre study of safety and efficacy of prone positioning for critically ill patients on veno-venous extracorporeal membrane oxygenation. Aust Crit Care 2020; 34:446-451. [PMID: 33303317 DOI: 10.1016/j.aucc.2020.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/18/2020] [Accepted: 10/18/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (VV-ECMO) may be used for patients with severe respiratory failure. Prone positioning may also be worthwhile using while patients are on VV-ECMO to promote return of native lung function. OBJECTIVES The aim of the study was to determine if the use of prone positioning in adult patients receiving VV-ECMO improved oxygenation, shortened the time on ECMO, and led to earlier liberation from ECMO compared with no prone positioning. We also wished to determine the incidence of pressure injury development in patients receiving prone positioning. METHODS This was a single-centre, retrospective cohort study of patients on VV-ECMO over 5 years at a national ECMO centre. FINDINGS Between July 1, 2014, and July 1, 2019, 72 patients were admitted to the cardiothoracic and vascular intensive care unit for VV-ECMO owing to respiratory failure. Patients were aged on average 46 years, male (n = 46, 64%), and New Zealand Europeans (n = 45, 63%). The most common diagnosis was pneumonia, the median ECMO treatment duration was 278 h, and 50 patients (69%) of the cohort survived to 6 months. Of these, 16 (22%) received at least one pronation procedure whilst on ECMO. Pronation increased oxygenation ratio although not significantly, and this increase was not sustained once returned to the supine position. Pronation was instituted late in the ECMO course and was not associated with complications. Prone episodes were carried out in a safe manner with few adverse events or complications. CONCLUSIONS In patients requiring VV-ECMO support, prone positioning would appear to be a safe intervention when carried out by an experienced team.
Collapse
Affiliation(s)
- Hanna Chaplin
- School of Nursing, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Shay McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, PO Box 110147, Auckland, 1142, New Zealand
| | - Rachael Parke
- School of Nursing, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, PO Box 110147, Auckland, 1142, New Zealand.
| |
Collapse
|
15
|
Rilinger J, Zotzmann V, Bemtgen X, Schumacher C, Biever PM, Duerschmied D, Kaier K, Stachon P, von Zur Mühlen C, Zehender M, Bode C, Staudacher DL, Wengenmayer T. Prone positioning in severe ARDS requiring extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:397. [PMID: 32641155 PMCID: PMC7341706 DOI: 10.1186/s13054-020-03110-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/29/2020] [Indexed: 01/19/2023]
Abstract
Background Prone positioning (PP) has shown to improve survival in patients with severe acute respiratory distress syndrome (ARDS). To this point, it is unclear if PP is also beneficial for ARDS patients treated with veno-venous extracorporeal membrane oxygenation (VV ECMO) support. Methods We report retrospective data of a single-centre registry of patients with severe ARDS requiring VV ECMO support between October 2010 and May 2018. Patients were allocated to the PP group if PP was performed during VV ECMO treatment or the supine positioning group. VV ECMO weaning success and hospital survival were analysed before and after propensity score matching. Results A total of 158 patients could be analysed, and 38 patients (24.1%) received PP. There were no significant differences in VV ECMO weaning rate (47.4% vs. 46.7%, p = 0.94) and hospital survival (36.8% vs. 36.7%, p = 0.98) between the prone and supine groups, respectively. The analysis of 38 propensity score matched pairs also showed no difference in hospital survival (36.8% vs. 36.8%, p = 1.0) or VV ECMO weaning rate (47.4% vs. 44.7%, p = 0.82). Hospital survival was superior in the subgroup of patients treated with early PP (cutoff < 17 h via Youden’s Index) as compared to late or no PP (81.8% vs. 33.3%, p = 0.02). Conclusion In this propensity score matched cohort of severe ARDS patients requiring VV ECMO support, prone positioning at any time was not associated with improved weaning or survival. However, early initiation of prone positioning was linked to a significant reduction of hospital mortality.
Collapse
Affiliation(s)
- Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany.
| | - Viviane Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Xavier Bemtgen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Carin Schumacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Paul M Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Manfred Zehender
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| |
Collapse
|
16
|
Dalmedico M, Ramos D, Hinata P, Alves W, Carvalho C, Avila J. Prone position and extracorporeal membrane oxygenation in acute respiratory distress syndrome. FISIOTERAPIA EM MOVIMENTO 2019. [DOI: 10.1590/1980-5918.032.ao35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: The acute respiratory distress syndrome is an inflammatory process originated by some pulmonary diseases, resulting in non-hydrostatic protein edema of the pulmonary parenchyma. The loss of the lung ability to eliminate carbon dioxide generates complications such as refractory hypoxemia, decreased alveolar dysplasia, increased complacency and hypercarbia. The treatment of acute respiratory distress syndrome, consist in measures to prevent lung diseases progression and optimize oxygenation. Objective: To identify, in the international scientific literature, cases or series of cases reporting the combined application of prone position and extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome, as well as the benefit of these rescue therapies. Method: This is a systematic review of case reports that show the benefit of combined therapies in the treatment of patients with acute respiratory distress syndrome. Results: From the research strategy and selection criteria were included 8 studies reporting 19 cases of patients with acute respiratory distress syndrome who received the combination of the two rescue therapies. All studies showed that extracorporeal membrane oxygenation was the primary intervention. There were no reports of adverse events. Conclusion: The combinations of therapies positively interfere on the prognosis of patients with acute respiratory distress syndrome, in addition to presenting no additional risks in terms of the occurrence of adverse events; however, the prone position should precede the extracorporeal membrane oxygenation as first-line intervention. PROSPERO Registration No. CRD42018093076
Collapse
|
17
|
Persico N, Guervilly C, Roch A, Papazian L. Extracorporeal membrane oxygenation in acute respiratory distress syndrome: why is the EOLIA trial important? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:S20. [PMID: 30613595 DOI: 10.21037/atm.2018.09.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Nicolas Persico
- Emergency Department, Hôpital Nord, APHM, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, France
| | - Christophe Guervilly
- Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord, APHM, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, France
| | - Antoine Roch
- Emergency Department, Hôpital Nord, APHM, Marseille, France.,Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord, APHM, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, France
| | - Laurent Papazian
- Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord, APHM, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, France
| |
Collapse
|
18
|
Patroniti N, Bonatti G, Senussi T, Robba C. Mechanical ventilation and respiratory monitoring during extracorporeal membrane oxygenation for respiratory support. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:386. [PMID: 30460260 DOI: 10.21037/atm.2018.10.11] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Over the past decade, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for respiratory support has widely expanded as a treatment strategy for patients with acute respiratory distress syndrome (ARDS). Despite considerable attention has been given to the indications, the timing and the management of patients undergoing ECMO for refractory respiratory hypoxemic failure, little is known regarding the management of mechanical ventilation (MV) in this group of patients. ECMO enables to minimize ventilatory induced lung injury (VILI) and it has been successfully used as rescue therapy in patients with ARDS when conventional ventilator strategies have failed. However, literature is lacking regarding the best strategies and MV settings, including positive end expiratory pressure (PEEP), tidal volume (VT), respiratory rate (RR) and plateau pressure (PPLAT). The aim of this review is to summarize current evidence, the rationale and provide recommendations about the best ventilator strategy to adopt in patients with ARDS undergoing VV-ECMO support.
Collapse
Affiliation(s)
- Nicolò Patroniti
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Giulia Bonatti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Tarek Senussi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy
| |
Collapse
|
19
|
Lucchini A, De Felippis C, Pelucchi G, Grasselli G, Patroniti N, Castagna L, Foti G, Pesenti A, Fumagalli R. Application of prone position in hypoxaemic patients supported by veno-venous ECMO. Intensive Crit Care Nurs 2018; 48:61-68. [PMID: 30037534 DOI: 10.1016/j.iccn.2018.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/18/2018] [Accepted: 04/04/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an advanced respiratory care therapy allowing replacement of pulmonary gas exchange. Despite VV-ECMO support, some patients may remain hypoxaemic. A possible therapeutic procedure for these patients is the application of prone positioning. OBJECTIVE The primary aim of the present study was to investigate modification of the PaO2/FiO2 ratio, in VV-ECMO patients with refractory hypoxaemia. The secondary aim was to evaluate the safety and feasibility of prone positioning for patients with severe Adult Respiratory Distress Syndrome supported by ECMO. METHODS We retrospectively reviewed the electronic records and charts of all patients supported by VV-ECMO who experienced at least one pronation. Complications related with prone positioning were also recorded. First PaO2/FiO2 ratio was analysed during four different time steps: before pronation, one hour after pronation, at the end of pronation and one hour after returning to supine. RESULTS A total of 45 prone positioning manoeuvers were performed in 14 VV-ECMO patients from November 2009 to November 2014. The median duration of prone positioning cycles was 8 hours (IQR 6-10). No accidental dislodgement of intravascular lines, endotracheal tubes, chest tubes or a decrease in ECMO blood flow was observed. During the first prone positioning for each patient, the median PaO2/FiO2 ratio recorded was 123 (IQR 82-135), 152 (93-185), 149 (90-186) and 113 (74-182), during PRE-supine step, 1 h-prone positioning step, END-prone positioning step, and POST-supine step respectively. CONCLUSIONS The application of prone positioning during VV-ECMO has shown to be a safe and reliable technique when performed in a recognised ECMO centre with the appropriately trained staff and standard procedures.
Collapse
Affiliation(s)
- Alberto Lucchini
- General Intensive Care Unit, Emergency Department - San Gerardo Hospital, University of Milan-Bicocca, Via Pergolesi 33, Monza (MB), Italy; University of Milan-Bicocca, Milan, Italy.
| | - Christian De Felippis
- Adult Intensive Care Unit, Glenfield Hospital, University Hospital of Leicester-NHS Trust, Groby Rd, Leicester LE3 9QP, United Kingdom
| | - Giulia Pelucchi
- General Intensive Care Unit, Emergency Department - San Gerardo Hospital, University of Milan-Bicocca, Via Pergolesi 33, Monza (MB), Italy
| | - Giacomo Grasselli
- General Intensive Care Unit - Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, MI, Italy
| | - Nicolò Patroniti
- General Intensive Care Unit, Emergency Department - San Gerardo Hospital, University of Milan-Bicocca, Via Pergolesi 33, Monza (MB), Italy
| | - Luigi Castagna
- General Intensive Care Unit - Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, MI, Italy
| | - Giuseppe Foti
- General Intensive Care Unit, Emergency Department - San Gerardo Hospital, University of Milan-Bicocca, Via Pergolesi 33, Monza (MB), Italy
| | - Antonio Pesenti
- General Intensive Care Unit - Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, MI, Italy
| | - Roberto Fumagalli
- University of Milan-Bicocca, Milan, Italy; Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda Hospital, Milan, Italy
| |
Collapse
|
20
|
Jansen O, Kamp O, Waydhas C, Rausch V, Schildhauer TA, Strauch J, Buchwald D, Hamsen U. Extracorporeal membrane oxygenation in spina bifida and (H1N1)-induced acute respiratory distress syndrome. J Artif Organs 2017; 20:354-358. [PMID: 28905112 PMCID: PMC7100752 DOI: 10.1007/s10047-017-0992-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 08/24/2017] [Indexed: 10/26/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized as an acute hypoxemic and/or hypercapnic respiratory failure seen in critically ill patients and is still, although decreased over the past few years, associated with high mortality. Furthermore, ARDS may be a life-threatening complication of H1N1 pneumonia. We report on a 45-year-old spina bifida patient with confirmed H1N1 influenza virus infection causing acute respiratory failure, who was successfully weaned from 42-day veno-venous extracorporeal membrane oxygenation (vv-ECMO) treatment with an excellent outcome. Due to the physical constitution of spina bifida patients, we experienced challenges concerning cannula positioning and mechanical ventilation settings during weaning.
Collapse
Affiliation(s)
- Oliver Jansen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Oliver Kamp
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Christian Waydhas
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
- Medical Faculty University Duisburg-Essen, Essen, Germany
| | - Valentin Rausch
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Justus Strauch
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| |
Collapse
|
21
|
Veno-arterial-ECMO in the intensive care unit: From technical aspects to clinical practice. Anaesth Crit Care Pain Med 2017; 37:259-268. [PMID: 29033360 DOI: 10.1016/j.accpm.2017.08.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 12/13/2022]
Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a salvage therapy in cardiogenic shock is becoming of current practice. While VA-ECMO is potentially a life-saving technique, results are sometimes mitigated, emphasising the need for selecting the right indication in the right patient. This relies upon a clear definition of the individual therapeutic project, including the potential for recovery as well as the possible complications associated with VA-ECMO. To maximise the benefits of VA-ECMO, the basics of extracorporeal circulation should be perfectly understood since VA-ECMO can sometimes be detrimental. Hence, to be successful, VA-ECMO should be used by teams with sufficient experience and initiated after a thorough multidisciplinary discussion considering patient's medical history, pathology as well the anticipated evolution of the disease.
Collapse
|
22
|
|
23
|
Zhang Z, Gu WJ, Chen K, Ni H. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure. Can Respir J 2017; 2017:1783857. [PMID: 28127231 PMCID: PMC5239989 DOI: 10.1155/2017/1783857] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/28/2016] [Accepted: 12/18/2016] [Indexed: 02/07/2023] Open
Abstract
Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.
Collapse
Affiliation(s)
- Zhongheng Zhang
- 1Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- *Zhongheng Zhang:
| | - Wan-Jie Gu
- 2Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China
| | - Kun Chen
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| | - Hongying Ni
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| |
Collapse
|
24
|
Cho YJ, Moon JY, Shin ES, Kim JH, Jung H, Park SY, Kim HC, Sim YS, Rhee CK, Lim J, Lee SJ, Lee WY, Lee HJ, Kwak SH, Kang EK, Chung KS, Choi WI. Clinical Practice Guideline of Acute Respiratory Distress Syndrome. Tuberc Respir Dis (Seoul) 2016; 79:214-233. [PMID: 27790273 PMCID: PMC5077725 DOI: 10.4046/trd.2016.79.4.214] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 06/27/2016] [Accepted: 08/16/2016] [Indexed: 12/29/2022] Open
Abstract
There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.
Collapse
Affiliation(s)
- Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ein-Soon Shin
- Research Agency for Clinical Practice Guidelines, Korean Academy of Medical Sciences Research Center, Seoul, Korea
| | - Je Hyeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hoon Jung
- Department of Pulmonary and Critical Care Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - So Young Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaemin Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Seok Jeong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Jeong Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sang Hyun Kwak
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Kyeong Kang
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | | | | |
Collapse
|
25
|
Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. [Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. Anaesthesist 2016; 64:596-611. [PMID: 26260196 DOI: 10.1007/s00101-015-0060-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
Collapse
Affiliation(s)
- T Bein
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, 93042, Regensburg, Deutschland,
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Two Therapies Are Better than One: Optimizing Recovery from ARDS. ASAIO J 2016; 62:217-8. [PMID: 27123954 DOI: 10.1097/mat.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
27
|
[Prone positioning of patients during venovenous extracorporeal membrane oxygenation is safe and feasible]. Anaesthesist 2016; 65:250-7. [PMID: 27007777 DOI: 10.1007/s00101-015-0131-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 12/04/2015] [Accepted: 12/09/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prone positioning of patients with acute respiratory distress syndrome (ARDS) has been shown to significantly improve survival rates. Prone positioning reduces collapse of dorsal lung segments with subsequent reduction of alveolar overdistension of ventral lung segments, optimizes lung recruitment and enhances drainage. Patients with ARDS treated by extracorporeal membrane oxygenation (ECMO) can also benefit from prone positioning; however, the procedure is associated with a possible higher risk of serious adverse events. OBJECTIVE The aim of this study was to evaluate the safety and feasibility of prone positioning for patients with severe ARDS during ECMO therapy. MATERIAL AND METHODS This study involved a retrospective analysis of all patients placed in a prone position while being treated by venovenous ECMO (vvECMO) for severe hypoxemia in ARDS as bridge to recovery in the interdisciplinary intensive care unit at the University Hospital Leipzig between January 2009 and August 2013. Baseline data, hospital mortality and serious adverse events were documented. Serious adverse events were defined as dislocation or obstruction of endotracheal tube or tracheal cannula, ECMO cannulas and cardiac arrest. Prone positioning was carried out by at least one doctor and three nurses according to a standardized protocol. Results are given as the median (1st and 3rd quartiles). RESULTS A total of 26 patients were treated with vvECMO as bridge to recovery due to severe ARDS. Causes for ARDS were pneumonia (n = 20) and aspiration (n = 2) and four patients had different rare causes of ARDS. The median time on ECMO was 8 days (6;11) and during this period 134 turning events were documented. Patients were proned for a median of 5 (3;7) periods with a median duration of 12 h (8;12). No serious adverse events were recorded. The hospital mortality was 42% and mortality during the ECMO procedure was 35%. CONCLUSION Prone positioning significantly reduces the mortality of patients with severe ARDS. In this series of 26 patients with severe ARDS during ECMO therapy no serious adverse events were found during the use of prone positioning.
Collapse
|
28
|
Cho YJ, Moon JY, Shin ES, Kim JH, Jung H, Park SY, Kim HC, Sim YS, Rhee CK, Lim J, Lee SJ, Lee WY, Lee HJ, Kwak SH, Kang EK, Chung KS, Choi WI. Clinical Practice Guideline of Acute Respiratory Distress Syndrome. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.2.76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ein-Soon Shin
- Research Agency for Clinical Practice Guidelines, Korean Academy of Medical Sciences Research Center, Seoul, Korea
| | - Je Hyeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea University College of Medicine, Korea
| | - Hoon Jung
- Department of Pulmonary and Critical Care Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - So Young Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Jaemin Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Gangneung Asan Hospital, University of Ulsan Medical College of Medicine, Gangneung, Korea
| | - Seok Jeong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Jeong Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Sang Hyun Kwak
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Eun Kyeong Kang
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | | |
Collapse
|
29
|
Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Anaesthesist 2015; 64 Suppl 1:1-26. [PMID: 26335630 PMCID: PMC4712230 DOI: 10.1007/s00101-015-0071-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
Collapse
Affiliation(s)
- Th Bein
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany.
| | - M Bischoff
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - U Brückner
- Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, 93093, Donaustauf, Germany
| | - K Gebhardt
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - D Henzler
- Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management, Klinikum Herford, 32049, Herford, Germany
| | - C Hermes
- HELIOS Clinic Siegburg, 53721, Siegburg, Germany
| | - K Lewandowski
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Elisabeth Hospital Essen, 45138, Essen, Germany
| | - M Max
- Centre Hospitalier, Soins Intensifs Polyvalents, 1210, Luxembourg, Luxemburg
| | - M Nothacker
- Association of Scientific Medical Societies (AWMF), 35043, Marburg, Germany
| | - Th Staudinger
- University Hospital for Internal Medicine I, Medical University of Wien, General Hospital of Vienna, 1090, Vienna, Austria
| | - M Tryba
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Klinikum Kassel, 34125, Kassel, Germany
| | - S Weber-Carstens
- Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, 13353, Berlin, Germany
| | - H Wrigge
- Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103, Leipzig, Germany
| |
Collapse
|
30
|
Kimmoun A, Roche S, Bridey C, Vanhuyse F, Fay R, Girerd N, Mandry D, Levy B. Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and respiratory compliance. Ann Intensive Care 2015; 5:35. [PMID: 26538308 PMCID: PMC4633431 DOI: 10.1186/s13613-015-0078-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/21/2015] [Indexed: 12/13/2022] Open
Abstract
Background Data are sparse regarding the effects of prolonged prone positioning (PP) during VV-ECMO. Previous studies, using short sessions (<12 h), failed to find any effects on respiratory system compliance. In the present analysis, the effects of prolonged PP sessions (24 h) were retrospectively studied with regard to safety data, oxygenation and respiratory system compliance. Methods Retrospective review of 17 consecutive patients who required both VV-ECMO and prone positioning. PP under VV-ECMO was considered when the patient presented at least one unsuccessful ECMO weaning attempt after day 7 or refractory hypoxemia combined or not with persistent high plateau pressure. PP sessions had a duration of 24 h with fixed ECMO and respiratory settings. PP was not performed in patients under vasopressor treatment and in cases of recent open chest cardiac surgery. Results Despite optimized protective mechanical ventilation and other adjuvant treatment (i.e. PP, inhaled nitric oxide, recruitment maneuvers), 44 patients received VV-ECMO during the study period for refractory acute respiratory distress syndrome. Global survival rate was 66 %. Among the latter, 17 patients underwent PP during VV-ECMO for a total of 27 sessions. After 24 h in prone position, PaO2/FiO2 ratio significantly increased from 111 (84–128) to 173 (120–203) mmHg (p < 0.0001) while respiratory system compliance increased from 18 (12–36) to 32 (15–36) ml/cmH2O (p < 0.0001). Twenty-four hours after the return to supine position, tidal volume was increased from 3.0 (2.2–4.0) to 3.7 (2.8–5.0) ml/kg (p < 0.005). PaO2/FiO2 ratio increased by over 20 % in 14/14 sessions for late sessions (≥7 days) and in 7/13 sessions for early sessions (<7 days) (p = 0.01). Quantitative CT scan revealed a high percentage of non-aerated or poorly-aerated lung parenchyma [52 % (41–62)] in all patients. No correlation was found between CT scan data and respiratory parameter changes. Hemodynamics did not vary and side effects were rare (one membrane thrombosis and one drop in ECMO blood flow). Conclusion When used in combination with VV-ECMO, 24 h of prone positioning improves both oxygenation and respiratory system compliance. Moreover, our study confirms the absence of serious adverse events. Electronic supplementary material The online version of this article (doi:10.1186/s13613-015-0078-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Antoine Kimmoun
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. .,INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, 54511, Vandoeuvre les Nancy, France. .,Université de Lorraine, 54000, Nancy, France.
| | - Sylvain Roche
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France.
| | - Céline Bridey
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France.
| | - Fabrice Vanhuyse
- INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, 54511, Vandoeuvre les Nancy, France. .,Université de Lorraine, 54000, Nancy, France. .,CHU Nancy, Département de Chirugie Cardiaque Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France.
| | - Renaud Fay
- INSERM, Centre d'Investigations Cliniques-9501 and CHU de Nancy, 54511, Vandoeuvre les Nancy, France.
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques-9501 and CHU de Nancy, 54511, Vandoeuvre les Nancy, France.
| | - Damien Mandry
- Université de Lorraine, 54000, Nancy, France. .,CHU Nancy, Département de Radiologie, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France.
| | - Bruno Levy
- CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. .,INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, 54511, Vandoeuvre les Nancy, France. .,Université de Lorraine, 54000, Nancy, France.
| |
Collapse
|
31
|
Marhong JD, Munshi L, Detsky M, Telesnicki T, Fan E. Mechanical ventilation during extracorporeal life support (ECLS): a systematic review. Intensive Care Med 2015; 41:994-1003. [PMID: 25752302 DOI: 10.1007/s00134-015-3716-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/24/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE In patients with acute respiratory distress syndrome (ARDS), extracorporeal life support (ECLS) has been utilized to support gas exchange and mitigate ventilator-induced lung injury (VILI). The optimal ventilation settings while on ECLS are unknown. The purpose of this systematic review is to describe the ventilation practices in patients with ARDS who require ECLS. METHODS We electronically searched MEDLINE, EMBASE, CENTRAL, AMED, and HAPI (inception to January 2015). Studies included were randomized controlled trials, observational studies, or case series (≥4 patients) of ARDS patients undergoing ECLS. Our review focused on studies describing ventilation practices employed during ECLS for ARDS. RESULTS Forty-nine studies (2,042 patients) met our inclusion criteria. Prior to initiation of ECLS, at least one parameter consistent with injurious ventilation [tidal volume >8 mL/kg predicted body weight (PBW), peak pressure >35 cmH2O (or plateau pressure >30 cmH2O), or FiO2 ≥0.8] was noted in 90% of studies. After initiation of ECLS, studies reported median [interquartile range (IQR)] reductions in: tidal volume [2.4 mL/kg PBW (2.2-2.9)], plateau pressure [4.3 cmH2O (3.5-5.8)], positive end-expiratory pressure (PEEP) [0.20 cmH2O (0-3.0)], and FiO2 [0.40 (0.30-0.60)]. Median (IQR) overall mortality was 41 % (31-51%). CONCLUSIONS Reduction in the intensity of mechanical ventilation in patients with ARDS supported by ECLS is common, suggesting that clinicians may be focused on reducing VILI after ECLS initiation. Future investigations should focus on establishing the optimal ventilatory strategy for patients with ARDS who require ECLS.
Collapse
Affiliation(s)
- Jonathan D Marhong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada,
| | | | | | | | | |
Collapse
|
32
|
Incomplete (135°) prone position as an alternative to full prone position for lung recruitment in ARDS during ECMO therapy. Wien Klin Wochenschr 2014; 127:149-50. [PMID: 25471001 DOI: 10.1007/s00508-014-0645-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 10/13/2014] [Indexed: 12/26/2022]
|